Bioidentical hormone therapy replaces the estrogen and progesterone your body makes less of in perimenopause and menopause, using hormones with the same molecular structure as your own. Some are FDA-approved products and some are compounded by a pharmacy to the dose your clinician writes, and the word "bioidentical" on its own doesn't tell you which.
Pill
A modestly higher risk of blood clots, stroke and heart attack than the skin routes. Still a reasonable choice for a healthy woman under 60 who prefers a pill.
Patch, gel, cream
Clotting factors don't rise. This is the route guidelines prefer for any woman with added clot risk.
Cream, tablet, ring
Treats dryness, painful sex and bladder symptoms on its own, with no progestogen needed. Progestogen is the umbrella term for progesterone and synthetic progestins, which act on the same receptors. It does nothing for hot flashes.
Commercial hormone products come in a handful of fixed strengths, and most people do well on one of them. If you need a dose that isn't made commercially, a compounding pharmacy can prepare it to the strength your clinician writes.
Hormone therapy is dosed to your symptoms, and the first prescription is rarely the last. A patch or a pill comes in a few set strengths, so an adjustment means moving to the next one up or down. A compounded prescription is a customized dose. It can fall between two commercial strengths and change in smaller steps at follow-ups, as a cream or a capsule. We also prescribe FDA-approved products, such as patches. Compounded hormones are not FDA-approved; the definition chapter below explains what that means.
A diagram with two rows: the top row marks a few evenly spaced commercial strengths; the bottom row shows a compounded dose starting between two of them, moving a small step at the first follow-up, and settling.
Estrogen is the one that treats hot flashes, night sweats, dryness and bone loss. Progesterone protects the uterine lining and has a calming effect that helps sleep and anxiety. Testosterone has one well-supported use, low sexual desire after menopause, and we prescribe it for patients in California only.
Symptoms
Treats hot flashes, night sweats, dryness and bone loss
Lining
Protects the uterine lining and helps sleep
Desire
For low sexual desire. Prescribed in California only
Hormone therapy is the most effective treatment for hot flashes, night sweats and vaginal symptoms, and it protects bone. Mood, brain fog, joint aches and desire often improve, less predictably. Weight gain, heart disease and dementia are not reasons to start it.
Decades of trials, large effects, and the symptoms a dose is judged on.
Fewer and milder for most women. This is the symptom the dose is judged on.
The same response, in bed. Sleep usually improves as the sweats do.
Systemic therapy helps. Low-dose vaginal estrogen treats it directly within a few weeks and can be used on its own, at any age.
Often better within a few weeks. Progesterone at bedtime has a calming effect that helps many women fall asleep and stay asleep.
Estrogen slows the bone loss that is fastest in the first years after the last period. Protection starts immediately and is measured over years.
These improve for many women, but not all. They can have causes other than hormones, and they take longer to respond.
Mood often improves on hormone therapy, and more so when night sweats and poor sleep are part of it. Typically four to twelve weeks.
Often lifts as sleep does. Hormone therapy is not a treatment for memory itself.
Many women notice stiffness ease in the first weeks; most of the effect takes two to three months.
Often improves as comfort, sleep and mood do. If low libido remains after that, estrogen alone rarely fixes it.
Low-dose vaginal estrogen is more effective than systemic therapy alone, and helps over one to three months.
Hormone therapy is prescribed for symptoms. These aren't symptoms.
Hormone therapy doesn't cause fat gain in trials, and it doesn't take weight off either. It can ease the sleep and joint problems that get in the way of exercise; the rest is food, strength training and time.
Hormone therapy is not FDA-approved to prevent heart disease. Some studies suggest that women who start it within 10 years of menopause may have a lower risk of heart disease.
It is not FDA-approved to prevent dementia either, and medical societies don't recommend hormone therapy for preventing it.
It treats menopause symptoms. It does not make anyone 35 again, and no one should promise you that.
The first video visit sets the form and a low starting dose. The next three months are for finding out what that dose does and adjusting it: most women need one or two changes, and two to three follow-ups are included in membership to make them.
Week 0
A one-on-one video visit to go over your symptoms, your history and your goals. We'll go over whether labs are needed to start, and choose the form together; our patch vs pill vs gel guide shows how.
Before starting
Not everyone needs this step. If a doctor thinks testing would change the plan (thyroid and anemia when fatigue is in the picture, for example), they'll order it. Labs repeat periodically once treatment starts.
Week 1
Dosing and hormone options are reviewed with you: a compounded cream or capsule, or an FDA-approved patch, gel or pill, with a progestogen if you have a uterus. Prescriptions go to your pharmacy and are priced there.
Weeks 1 to 6
Hot flashes usually ease within two weeks. Early side effects can include breast tenderness, bloating, spotting or a groggy morning from progesterone. They ease over time or with a dose adjustment, most within several days to several weeks; what's normal and what's fixable.
Weeks 6 to 12
The first follow-up. Sweats still going strong mean a step up; tenderness or headaches that haven't faded might mean a step down. How dose adjustments work.
Month 3 onward
The full effect of a dose is in by about three months: the symptom-by-symptom timeline. Follow-ups continue under membership, with HIPAA-compliant messaging and labs repeated periodically.
Your first visit is $99. One month after that visit, membership begins at $49 a month and is required for refills and ongoing care. Prescriptions and lab tests are priced separately; lab prices depend on what is tested.
First visit
$99
One video visit with a clinician licensed in your state. Refunded in full if you cancel at least 24 hours ahead.
Membership
$49 a month
Begins one month after your first visit. Two to three follow-ups, HIPAA-compliant messaging, and dose adjustments. Required for refills and ongoing care; cancel any time.
Prescriptions and labs
Priced separately
Only what your plan needs. Prescriptions depend on your plan; lab tests depend on what is tested.
For women who start within 10 years of menopause, the benefits outweigh the risks. Breast cancer: a small increase with some combined regimens used for several years, and none on estrogen alone.
2025
In 2002 the Women’s Health Initiative study was widely reported as linking hormone therapy to breast cancer, heart disease and dementia, and boxed warnings followed. In November 2025, after reviewing newer evidence, the FDA announced it is starting to remove those boxed warnings from menopausal hormone therapy products. The labeling will recommend starting systemic hormone therapy within 10 years of menopause or before age 60.
Read the FDA announcement (opens in a new tab)Two rows of 10,000 women each: on combined estrogen and progestin, about 8 more breast cancer cases a year than on placebo; on estrogen alone after a hysterectomy, no increase.
Estrogen and progestin
+8a year
Estrogen alone
0no increase
What affects your risk
Clots, stroke and heart attack are linked mainly to oral estrogen. Estrogen through the skin skips the liver's first pass.
Your age, time since menopause, and a history of clots, stroke, breast cancer, liver disease or migraine with aura change the calculation.
Low-dose vaginal estrogen is different: very little reaches the bloodstream, so these risks don't apply.
Bring your history to the first visit; that's what it's for.
Refunded if you cancel 24 hours ahead.
Bioidentical describes the molecule, not the product. Many FDA-approved hormone therapy products are bioidentical, and so are the ones from a compounding pharmacy.
Estradiol is estradiol whether your ovary made it or a factory did. Most pharmaceutical estradiol and progesterone start from plant sterols, which is where "plant-based" comes from, and the finished molecule is identical to yours. That is all the word means. It says nothing about whether a product is FDA-approved, safe, or right for you.
The word covers two kinds of product. FDA-approved bioidentical products are estradiol patches, gels, sprays, pills and vaginal preparations, and oral micronized progesterone, manufactured in set strengths to a tested potency and studied in trials. Compounded bioidentical hormones are made to order by a compounding pharmacy, to the dose and form on the prescription, usually as creams or capsules, sometimes with several hormones combined.
Your provider will explain when a compounded option may be a good alternative to an FDA-approved product. You'll be told which you're getting and why. The BHRT vs HRT guide takes the comparison further.
The older products are still around too. Conjugated equine estrogens and synthetic progestins such as medroxyprogesterone acetate are FDA-approved and act on estrogen and progesterone receptors, though medroxyprogesterone also acts on cortisol and androgen receptors; they are what the 2002 Women's Health Initiative study used.
Examples, by molecule
Dr. Ashley Alexis, ND. Dr. Steve Groke, MD. Mai Tran, PharmD, a compounding pharmacist advisor. Menopause care is all we do.
Prescriptions come from a clinician licensed in your state. If your state isn't listed, we can't prescribe there yet. Menopause 101 and the symptom guides are open to everyone, and the office answers questions at (760) 542-8898.
For most women who start within 10 years of menopause or before 60, the benefits outweigh the risks; starting later means the risks need a closer look, not that you can't. "Bioidentical" doesn't make a hormone safer. The dose, the route, the progestogen and your history do. The risks that remain are blood clots, stroke and heart attack, mainly with oral estrogen, and a small increase in breast cancer with some combined regimens used for several years.
Many are. Estradiol patches, gels, sprays, pills and vaginal products, and oral micronized progesterone, are FDA-approved bioidentical hormones. Hormones made to order by a compounding pharmacy are not FDA-approved; they are made to the dose and form on the prescription, which lets a clinician adjust in smaller steps. Your provider will explain when a compounded option may be a good alternative to an FDA-approved product, and you'll be told which you're getting.
Mostly the label. HRT is the general term for hormone therapy in menopause; bioidentical means the molecule matches yours, and many FDA-approved HRT products are bioidentical. The real choices are which hormone, which route, and an approved product or a compounded one. Our BHRT vs HRT guide takes it apart.
Hot flashes usually ease within two weeks, most of the benefit arrives by four to eight weeks, and the full effect of a dose takes about three months. The symptom-by-symptom timeline has the detail.
Your doctor will go over at your first visit whether lab testing is needed to begin treatment. If you're over 45 with typical symptoms, the diagnosis is clinical and treatment can start on that basis. Once treatment starts, labs are repeated periodically to monitor how it's working. Testosterone is the exception: a blood level is always checked.
No. Pellets are small implants placed under the skin that release estradiol or testosterone for months. Once in, the dose can't be lowered or taken out, and levels often run above the normal range. The Menopause Society doesn't recommend them. We prescribe patches, gels, creams, pills and vaginal forms instead.
We don't take insurance. We do accept FSA and HSA payments, for the first visit and the membership. FDA-approved prescriptions are often covered by insurance. The pricing page has the refund and cancellation rules.
After a hysterectomy, yes. After 60, it isn't ruled out; it means a closer look at your history and clot risk, and usually a patch or gel rather than a pill. Low-dose vaginal estrogen can be started at any age.
For patients in California only. The evidence is for postmenopausal women with distressing low desire: a female-dose gel or cream improves desire in trials. No testosterone product is FDA-approved for women in the US, so it's off-label or compounded, with blood levels checked. Outside California, we can treat low libido: low-dose vaginal estrogen for dryness and painful sex, hormone therapy for night sweats and broken sleep. More on our low libido page.
A $99 video visit with a clinician who prescribes this every day, in 33 states. Refunded if you cancel 24 hours ahead.
