BHRT vs. HRT: Navigating Menopause Treatment Options

When it comes to the differences between traditional hormone replacement therapy (HRT) and bioidentical hormone replacement therapy (BHRT) for menopause there’s a lot of confusion. A LOT.

Companies that sell bioidentical hormone therapy often market these hormones as a healthier and safer alternative to traditional HRT (also called menopause hormone therapy or MHT). And their efforts seem to be paying off: The Menopause Society estimates that 40 percent of menopause patients use bioidentical hormone therapy to manage symptoms like hot flashes, insomnia, joint pain, and mood swings, according to a 2021 study. ¹

What you may not realize is that many FDA-approved forms of traditional HRT are also bioidentical—a fact that even some healthcare providers are unaware of, according to a 2016 study. ² The American College of Obstetricians and Gynecologists (ACOG) notes this lack of awareness has led women to seek compounded bioidentical hormone therapies, mistakenly believing these are the only natural options. ³

And while there’s little evidence that compounded BHRT is safer and more effective than synthetic HRT, that doesn’t mean compounded BHRT is always unsafe or ineffective.

Confused yet? It’s understandable. Let’s break it down.

About the Experts

Natalie Kunsman, M.D., M.S., is a board-certified family physician and integrated physician who treats women in menopause.

Liz Lyster, M.D., is an ob/gyn and menopause specialist based in San Francisco, CA.

The Main Differences Between BHRT and HRT

The primary difference between BHRT and HRT is the source and structure of the hormones. ⁴

• Hormone Replacement Therapy (HRT) is made with animal-derived versions of estrogen and synthetic progesterone (called progestogens or progestins). These hormones are structurally very similar to the ones your body makes and act the same way in the body.
• Bioidentical Hormone Replacement Therapy (BHRT) is made with estrogens and progesterone derived from plant sources like wild yams or soy. Structurally, they are exactly or almost exactly the same as what your body makes.

All forms of hormone therapy are prescribed to treat menopause symptoms like hot flashes, joint pain, vaginal dryness, and sleep disturbances.

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The History of BHRT vs HRT

In the 1990s, Premarin—an estrogen derived from the urine of pregnant mares—was the most-prescribed drug in the U.S. Then, in 2002, the Women’s Health Initiative (WHI) study initially reported increased risks of stroke and breast cancer in women taking Premarin. Prescriptions for HRT plummeted, and many women started to seek natural alternatives, fueling demand for bioidentical hormones. ⁵

Subsequent reanalysis of the WHI study has shown the cancer and heart disease risks for HRT were vastly overstated. Today, the general medical consensus supports HRT as a safe and effective treatment for most menopausal women, particularly when started before age 60 or within 10 years of menopause. ⁶

Still, many women and providers remain confused about BHRT vs HRT. So it’s worth looking at some of the claims, the science, and what the evidence actually says.

Is BHRT More Natural Than HRT?

BHRT is marketed as more natural than HRT because of the source of the hormones. As noted, synthetic HRT is derived from animals or lab-produced chemicals. BHRT is derived from plant sources, but it still undergoes lab processing.

Some forms of traditional HRT are bioidentical; they just aren’t marketed that way. For example, FDA-approved pharmaceutical bioidentical hormones—like estradiol and micronized progesterone—are plant-derived. Like synthetic HRT, these medications have been rigorously tested in clinical trials, manufactured to FDA standards, and are only available in specific dosages. ⁷

Is BHRT More Effective Than HRT?

Another oft-cited claim about BHRT is that it’s more effective than synthetic HRT because of its chemical structure. “Bioidentical means that the form of the hormone being used is exactly or almost exactly the same as what the woman’s body used to make,” says OB/GYN and menopause specialist Liz Lyster, M.D.

For estrogen and progesterone to effectively supplement the body’s hormones, they have to lock into their receptors on the surface of cells. In theory, the more similar these hormones are to your natural hormones, the better they’ll fit into their receptors. In reality, this difference may not matter.

Synthetic HRT is highly similar and engineered to work in the same way as your natural hormones. And claims that BHRT is easier for your body to absorb because it acts more like your body’s natural hormones aren’t backed by research. ⁸

Is BHRT is Safer Than HRT?

The hormones in FDA-approved HRT—including bioidentical pharmaceutical hormones and synthetic ones—are manufactured according to the FDA’s standards. They’ve been tested in clinical trials, and an abundance of studies confirm they relieve menopause symptoms and protect bones against osteoporosis. ⁹

In contrast, compounded BHRT isn’t FDA-approved. ¹⁰ While the individual ingredients may have been studied in clinical trials and FDA-approved, the specific doses and formulations custom-made by compounding pharmacies haven’t been tested for safety and effectiveness, says integrative physician Natalie Kunsman, M.D.

Because compounded BHRT lacks standardization and regulatory oversight, major medical organizations—including ACOG and The Menopause Society critique the lack of evidence around its safety and effectiveness and don’t recommend it when FDA-approved formulations are available. ^{11 12}

Is Compounded BHRT Better Because It’s More Personalized?

While FDA-approved HRT uses pre-determined dosages and formulations, compounded BHRT is custom-made by compounding pharmacies and can contain hormones (or blends of hormones) such as estrone, estriol, and progesterone. ¹³

The doses of compounded bioidentical hormones are tailor-made based on the prescription your doctor writes. For example, if your doctor wants you to have more than the standard 100 mg dose of a medication but less than the standard 200 mg dose, a compounding pharmacist can custom-make a 150 mg dose for you.

Compounding can have its downsides, including a lack of standardization, testing, and FDA approval. However, Kunsman notes that these criticisms may not be entirely justified since the ingredients in compounded BHRT are FDA-approved for use in humans, and compounding pharmacists must abide by rigorous safety standards to prevent mistakes and contamination.

Organizations like ACOG and the Menopause Society acknowledge that there are situations when compounded BHRT might be worth trying.

For example, some synthetic progesterone capsules are made with peanut oil, which could be dangerous if you have a peanut allergy. Or, you may need a specific dose of HRT that isn’t commercially available.

Some BHRT companies claim they can tailor therapy to individuals by measuring hormone levels using saliva tests. However, estrogen levels in saliva fluctuate significantly, making these tests poor indicators of actual hormone levels. What’s more, none of these tests are FDA-approved to measure estrogen and progesterone. ¹⁴

HRT vs. BHRT: Key Comparisons

Similarities Between BHRT and HRT

Regardless of whether you opt for BHRT or HRT, there are a few things to keep in mind.

Types of BHRT and HRT

Both BHRT and HRT come in a variety of formulations:

• Systemic: the hormones are delivered into the bloodstream and spread throughout the body via pills, patches, injections, and sprays
• Localized: the hormones are delivered directly to the vagina and surrounding tissues, like vaginal rings, suppositories, and creams).

If you still have a uterus, you’ll need to take both estrogen and progesterone or progestin (synthetic progesterone) to stop cells in your uterus from growing too much and developing into uterine cancer. Women who have had a hysterectomy can take estrogen unopposed (without progesterone).

Dosage for BHRT vs HRT

The dosages of HRT and pharmaceutical BHRT vary based on the product and are standardized for consistency. Compounded BHRT doses are created to your doctor’s specifications.

Cost of BHRT vs HRT

How much you pay for hormone therapy depends on the formulation, dose, and your insurance coverage. Costs for pharmaceutical HRT and BHRT should be about equal, but with compounded products, you might pay more.

For one thing, there aren’t any less-expensive generic versions, like there are for some pharmaceutical hormones. And compounded BHRT is often not covered by medical insurance, says Lyster.

But in some cases, you may pay less, since compounded medications are usually cheaper than brand-name medications.

Risks and Side Effects

Both HRT and BHRT come with increased risk for certain conditions, including: ^{15 16}

• Cardiovascular disease
• Blood clots and stroke
• Gallbladder disease
• Uterine cancer (if you still have your uterus and don’t take progesterone with estrogen)
• Breast cancer (with long-term use)

However, how you take these hormones may affect your heart risks more than whether they’re bioidentical or not.

“When you swallow anything by mouth, it goes down into your stomach and straight over to the liver,” explains Lyster. In the liver, estrogen stimulates the formation of clotting factors, which is why there’s an increased risk of blood clots and stroke. Patches and other topical versions that go through your skin bypass your liver, and largely avoid these risks.