Gillian Goddard

6 min Read Gillian Goddard

Gillian Goddard

Bioidentical Hormones for HRT in Menopause

Are natural treatments better?

Gillian Goddard

6 min Read

Recently a patient and I were discussing whether she might benefit from hormone replacement therapy (HRT). She was having hot flushes and night sweats and her sleeping was disrupted. We decided HRT might help her feel better. She expressed a preference for the most natural options, and she asked to consider bioidentical hormones. 

The patient had friends who had used bioidentical hormones, and she sheepishly admitted she had been reading about them online (patients often worry I will be upset about their internet reading, but I find when patients have done a little reading in advance, it can be helpful, as long as they keep an open mind about how to proceed). She wanted to know: were they truly more natural and were they safer? She knew bioidentical options were expensive, but she was willing to spend the money if I thought there were benefits. 

The popularity of bioidentical hormones has soared since the Women’s Health Initiative (WHI) studies were published more than 20 years ago. They have been promoted as a safer, more natural option for relieving perimenopausal symptoms. But what exactly are bioidentical hormones, and are they really better than estrogen in a patch or gel off the shelf at your pharmacy?

What are bioidentical hormones?

Technically, a bioidentical hormone is one that is chemically exactly the same as the hormone that your body produces. But in practical terms, bioidentical HRT refers to custom-compounded creams that contain estrogen — typically estradiol and also sometimes estriol, which we will get to in a moment — often along with progesterone, testosterone, and a few other less well-known hormones. The doses of the component hormones are adjusted based on frequent testing of blood levels of the hormones for each individual. For the sake of clarity, we will refer to this type of HRT as compounded HRT.

To understand how the estrogens in compounded HRT are different (or not) from those in conventional HRT, I think it is helpful to know about the estrogens used in conventional HRT. There are two types. The first, conjugated equine estrogens (CEE), are isolated from the urine of pregnant horses and are used in formulations like Prempro. CEE is the type of estrogen used in all the WHI studies. 

The second type of estrogen, estradiol — sometimes called 17β-estradiol, or 17-beta-estradiol — is created by chemically modifying estrogen-like substances extracted from plants. It is the estrogen found in estrogen patches and gels. This is the type of estrogen used in compounded HRT.

All estradiol is bioidentical in that it is structurally the same estrogen as our ovaries make. The process used to convert plant extracts into estradiol is the same whether we are talking about commercially produced patches and gels or estradiol used in compounded HRT.

What is estriol and is it important?

One of the most common brands of estradiol used in compounded HRT is Bi-Est. As the name suggests, Bi-Est contains two types of estrogen: a plant-derived estradiol like we discussed above and estriol. 

Estriol is a form of estrogen best understood for its role in pregnancy. In fact, it is the main form of estrogen the body makes during pregnancy. Outside of pregnancy, its role is poorly understood, but it seems to be effective in treating perimenopausal symptoms and may cause fewer side effects like increased growth of the uterine lining and vaginal bleeding.  

Estriol is best studied as a cream or suppository given vaginally, not in a transdermal cream like most compounded HRT. Right now it is not approved by the FDA for any indication, so there are no off-the-shelf forms of estriol available in the U.S. at this time. It is only available from compounding pharmacies. In Europe, estriol is widely available as oral pills, vaginal creams and vaginal suppositories.

Are compounded bioidentical formulations effective?

A Cochrane review of the safety and effectiveness of bioidentical hormones used to treat perimenopausal symptoms looked at data from 23 randomized controlled trials. In most of the trials included in the review, estradiol was given in commercially available patches and gels. Only one of the included studies compared estradiol in a compounded emulsion to a placebo. That study found no difference in symptoms between the treatment group and the placebo group, but the authors note that the quality of the data was poor. 

In another randomized controlled trial, researchers assigned 40 women HRT in one of three doses of Bi-Est in a compounded cream or an estradiol patch (Vivelle-Dot) in a comparable dose. They measured estradiol and estriol levels in the women’s blood before and after starting HRT.

They found that estrogen levels in the women receiving Bi-Est were consistently and statistically significantly lower than the women receiving estradiol via patch. Estriol levels did not change at all in any of the groups. This suggests that Bi-Est is less efficient at raising estrogen levels, but the study did not focus on how well the products managed the women’s perimenopausal symptoms.

What is the difference between off-the-shelf and compounded medications?

In the United States, medications available at your regular pharmacy must be approved by the FDA (there are analogous agencies in other countries). Beyond just looking at the data regarding the safety and efficacy of a medication, the FDA sets and enforces standards for quality control and manufacturing processes. The goal of these standards is to be sure that when you pick up your prescription at the pharmacy, it is exactly the same as what the label says it is, regardless of where you are and where it was manufactured.

Compounded medications and compounding pharmacies are not subject to these regulations. In fact, the regulation of compounding pharmacies and the safety and quality of the product they are required to produce varies widely depending on where the pharmacy is licensed. It is difficult to know if the compounded product you receive contains the medication and dose it is supposed to.   

The other big difference between off-the-shelf medications and compounded medications is cost. Prescription drug coverage under your insurance plan typically covers prescription drugs for the indication for which they were approved by the FDA. It does not typically cover the cost of compounded medications. Compounded HRT can cost upward of $500 for a one-month supply. Depending on your insurance, a generic estradiol patch may cost you just a few dollars per month. 

Ultimately, the estradiol in compounded HRT is not safer, more natural, or more effective than the estradiol available at your regular pharmacy in patches and gels, because the estradiol in both products is chemically the same. The two most common estrogens found in compounded HRT have been shown to be safe and effective in managing perimenopausal symptoms. But compounded HRT is typically more expensive than off-the-shelf options and is not subject to the same quality controls. If you do decide to try a “bioidentical” compounded product, be sure to work with your doctor to find a reputable compounding pharmacy. 

0 Comments
Inline Feedbacks
View all comments
Menopausal woman staring

Mar 12 2024

6 min read

Does Taking Estrogen Lower the Risk for Dementia?

This summer, my grandmother died at the age of 99 (11 months shy of her goal of 100) from dementia. Read more

Gillian Goddard
Woman with headache

Mar 15 2024

3 min read

How Can I Manage My Headaches in Perimenopause?

Migraines and headaches and perimenopause — they aren’t easily controlled by the usual medications, and made worse by HRT. But Read more

Gillian Goddard
Doctor and patient on pink background

Mar 19 2024

9 min read

Hormone Replacement Therapy for Menopause Symptoms

A couple of years ago, I met a new patient. In the course of our conversation, she noted that she Read more

Gillian Goddard
Frustrated person with head in hands

Mar 29 2024

2 min read

Can I Start HRT for Mood Alone?

I’d like to start HRT. At 49 I am still having periods, albeit less regularly. My main concern is emotional Read more

Gillian Goddard

Instagram

left right
The list of what not to do while pregnant feels longer than a CVS receipt. At ParentData, we want to empower you to make the right decisions for you. 

What an amazing group of women, and an honor to speak at the #MomsFirstSummit debunking parenting myths. 

What are some pregnancy rules you chose to bend after being empowered by data?

#emilyoster #parentdata #pregnancyproblems #pregnancymyths

The list of what not to do while pregnant feels longer than a CVS receipt. At ParentData, we want to empower you to make the right decisions for you.

What an amazing group of women, and an honor to speak at the #MomsFirstSummit debunking parenting myths.

What are some pregnancy rules you chose to bend after being empowered by data?

#emilyoster #parentdata #pregnancyproblems #pregnancymyths
...

Looking for Memorial Day Weekend plans? Might be the perfect time to give potty training a shot. Potty training is notoriously difficult, and we unfortunately don’t have a lot of evidence-based guidance on what works best. So I asked the ParentData community to fill out a survey and share their knowledge — about 6,000 people responded.

👉Comment “Link” for a DM to an article that summarizes all of the best potty training advice we collected. 

Remember, you are not alone in the potty training struggle! It can be incredibly challenging, so please give yourself some grace.

#emilyoster #parentdata #pottytraining #pottytrainingtips #toddlertips

Looking for Memorial Day Weekend plans? Might be the perfect time to give potty training a shot. Potty training is notoriously difficult, and we unfortunately don’t have a lot of evidence-based guidance on what works best. So I asked the ParentData community to fill out a survey and share their knowledge — about 6,000 people responded.

👉Comment “Link” for a DM to an article that summarizes all of the best potty training advice we collected.

Remember, you are not alone in the potty training struggle! It can be incredibly challenging, so please give yourself some grace.

#emilyoster #parentdata #pottytraining #pottytrainingtips #toddlertips
...

We’re hiring an Associate Editor at ParentData! More details at my link in bio. Please share with the great writers and data-loving people in your network. 📊💻

We’re hiring an Associate Editor at ParentData! More details at my link in bio. Please share with the great writers and data-loving people in your network. 📊💻 ...

Do you brand things a certain way to get your kid to accept it? Like calling carrots “rabbit popsicles”? Or telling them to put on their “super speed socks” in the morning? Share your rebrands in the comments below! You never know who you might be helping out 👇

#emilyoster #funnytweets #relatabletweets #parentingjokes #kidssaythedarndestthings

Do you brand things a certain way to get your kid to accept it? Like calling carrots “rabbit popsicles”? Or telling them to put on their “super speed socks” in the morning? Share your rebrands in the comments below! You never know who you might be helping out 👇

#emilyoster #funnytweets #relatabletweets #parentingjokes #kidssaythedarndestthings
...

Have you ever panic-googled a parenting question when everyone else is asleep? If so, you’re not alone. 

Today is the first episode of a new biweekly series on my podcast: Late-Night Panic Google. On these mini-episodes, you’ll hear from some familiar names about the questions keeping them up at night, and how data can help. First up: @claireholt!

Listen and subscribe to ParentData with Emily Oster in your favorite podcast app 🎧

#parentdata #emilyoster #claireholt #parentingstruggles #parentingtips #latenightpanicgoogle

Have you ever panic-googled a parenting question when everyone else is asleep? If so, you’re not alone.

Today is the first episode of a new biweekly series on my podcast: Late-Night Panic Google. On these mini-episodes, you’ll hear from some familiar names about the questions keeping them up at night, and how data can help. First up: @claireholt!

Listen and subscribe to ParentData with Emily Oster in your favorite podcast app 🎧

#parentdata #emilyoster #claireholt #parentingstruggles #parentingtips #latenightpanicgoogle
...

Sun safety is a must for all ages, especially babies! Here are my tips for keeping your littlest ones protected in the sunshine:
☀️ Most importantly, limit their time out in hot weather. (They get hotter than you do!)
☀️ Keep them in the shade as much as possible when you’re out.
☀️ Long-sleeve but lightweight clothing is your friend, especially on the beach, where even in the shade you can get sunlight reflecting off different surfaces.
☀️ If you want to add a little sunscreen on their hands and feet? Go for it! But be mindful as baby skin tends to more prone to irritation.

Comment “Link” for a DM to an article on the data around sun and heat exposure for babies.

#sunsafety #babysunscreen #babyhealth #parentdata #emilyoster

Sun safety is a must for all ages, especially babies! Here are my tips for keeping your littlest ones protected in the sunshine:
☀️ Most importantly, limit their time out in hot weather. (They get hotter than you do!)
☀️ Keep them in the shade as much as possible when you’re out.
☀️ Long-sleeve but lightweight clothing is your friend, especially on the beach, where even in the shade you can get sunlight reflecting off different surfaces.
☀️ If you want to add a little sunscreen on their hands and feet? Go for it! But be mindful as baby skin tends to more prone to irritation.

Comment “Link” for a DM to an article on the data around sun and heat exposure for babies.

#sunsafety #babysunscreen #babyhealth #parentdata #emilyoster
...

I’m calling on you today to share your story. I know that many of you have experienced complications during pregnancy, birth, or postpartum. It’s not something we want to talk about, but it’s important that we do. Not just for awareness, but to help people going through it feel a little less alone.

That’s why I’m asking you to post a story, photo, or reel this week with #MyUnexpectedStory and tag me. I’ll re-share as many as I can to amplify. Let’s fill our feeds with these important stories and lift each other up. Our voices can create change. And your story matters. 💙

#theunexpected #emilyoster #pregnancycomplications #pregnancystory

I’m calling on you today to share your story. I know that many of you have experienced complications during pregnancy, birth, or postpartum. It’s not something we want to talk about, but it’s important that we do. Not just for awareness, but to help people going through it feel a little less alone.

That’s why I’m asking you to post a story, photo, or reel this week with #MyUnexpectedStory and tag me. I’ll re-share as many as I can to amplify. Let’s fill our feeds with these important stories and lift each other up. Our voices can create change. And your story matters. 💙

#theunexpected #emilyoster #pregnancycomplications #pregnancystory
...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

Is side sleeping important during pregnancy? Comment “Link” for a DM to an article on whether sleep position affects pregnancy outcomes.

Being pregnant makes you tired, and as time goes by, it gets increasingly hard to get comfortable. You were probably instructed to sleep on your side and not your back, but it turns out that advice is not based on very good data.

We now have much better data on this, and the bulk of the evidence seems to reject the link between sleep position and stillbirth or other negative outcomes. So go ahead and get some sleep however you are most comfortable. 💤

Sources:
📖 #ExpectingBetter pp. 160-163
📈 Robert M. Silver et al., “Prospective Evaluation of Maternal Sleep Position Through 30 Weeks of Gestation and Adverse Pregnancy Outcomes,” Obstetrics and Gynecology 134, no. 4 (2019): 667–76. 

#emilyoster #pregnancy #pregnancytips #sleepingposition #pregnantlife

Is side sleeping important during pregnancy? Comment “Link” for a DM to an article on whether sleep position affects pregnancy outcomes.

Being pregnant makes you tired, and as time goes by, it gets increasingly hard to get comfortable. You were probably instructed to sleep on your side and not your back, but it turns out that advice is not based on very good data.

We now have much better data on this, and the bulk of the evidence seems to reject the link between sleep position and stillbirth or other negative outcomes. So go ahead and get some sleep however you are most comfortable. 💤

Sources:
📖 #ExpectingBetter pp. 160-163
📈 Robert M. Silver et al., “Prospective Evaluation of Maternal Sleep Position Through 30 Weeks of Gestation and Adverse Pregnancy Outcomes,” Obstetrics and Gynecology 134, no. 4 (2019): 667–76.

#emilyoster #pregnancy #pregnancytips #sleepingposition #pregnantlife
...

My new book, “The Unexpected: Navigating Pregnancy During and After Complications” is available for preorder at the link in my bio!

I co-wrote #TheUnexpected with my friend and maternal fetal medicine specialist, Dr. Nathan Fox. The unfortunate reality is that about half of pregnancies include complications such as preeclampsia, miscarriage, preterm birth, and postpartum depression. Because these are things not talked about enough, it can not only be an isolating experience, but it can also make treatment harder to access.

The book lays out the data on recurrence and delves into treatment options shown to lower risk for these conditions in subsequent pregnancies. It also guides you through how to have productive conversations and make shared decisions with your doctor. I hope none of you need this book, but if you do, it’ll be here for you 💛

#pregnancy #pregnancycomplications #pregnancyjourney #preeclampsiaawareness #postpartumjourney #emilyoster

My new book, “The Unexpected: Navigating Pregnancy During and After Complications” is available for preorder at the link in my bio!

I co-wrote #TheUnexpected with my friend and maternal fetal medicine specialist, Dr. Nathan Fox. The unfortunate reality is that about half of pregnancies include complications such as preeclampsia, miscarriage, preterm birth, and postpartum depression. Because these are things not talked about enough, it can not only be an isolating experience, but it can also make treatment harder to access.

The book lays out the data on recurrence and delves into treatment options shown to lower risk for these conditions in subsequent pregnancies. It also guides you through how to have productive conversations and make shared decisions with your doctor. I hope none of you need this book, but if you do, it’ll be here for you 💛

#pregnancy #pregnancycomplications #pregnancyjourney #preeclampsiaawareness #postpartumjourney #emilyoster
...

We are better writers than influencers, I promise. Thanks to our kids for filming our unboxing videos. People make this look way too easy. 

Only two weeks until our book “The Unexpected” is here! Preorder at the link in my bio. 💙

We are better writers than influencers, I promise. Thanks to our kids for filming our unboxing videos. People make this look way too easy.

Only two weeks until our book “The Unexpected” is here! Preorder at the link in my bio. 💙
...