Bioidentical hormones and pellets
"Bioidentical" sounds natural and safe, and it's often sold that way. The real story is more useful: you can get bioidentical hormones without the downsides of compounding.
The short answer: bioidentical hormones match the structure of your own. FDA-approved bioidentical estradiol (as patches, gels, sprays or pills) and micronized progesterone are tested for dose and purity, and covered by most insurance. That's what we prescribe for most women. Custom-compounded hormones and implanted pellets aren't regulated the same way, and pellets can push hormone levels well above normal with no way to remove them.
What "bioidentical" actually means
A bioidentical hormone has exactly the same molecular structure as one your body produces. Estradiol, the main estrogen before menopause, and progesterone are both available in bioidentical form. Older products, such as conjugated estrogens and synthetic progestins, are chemically different, though still effective.
The confusion comes from marketing. "Bioidentical" is often used to mean "custom-compounded," as if the two go together. They don't. Some of the most widely prescribed FDA-approved hormones are bioidentical:
- Estradiol patches, gels, sprays, pills and vaginal products
- Micronized progesterone capsules, often taken at bedtime
- Combined estradiol and progesterone in a single capsule
The problem with compounding
Compounding pharmacies mix hormones to order, often as creams or troches. For most women, that creates problems without adding benefits:
- Dose and purity aren't FDA-checked, so what you get can vary from batch to batch
- Compounded progesterone creams may not protect the uterus reliably
- They come without standard safety information
- They're usually not covered by insurance
A 2020 National Academies review found insufficient evidence that compounded bioidentical hormones are safer or more effective than approved products.
The problem with pellets
Pellets are small implants placed under the skin that release estradiol, testosterone or both over several months. They're heavily marketed, but:
- They can't be removed if you have side effects
- They often produce hormone levels well above the normal range
- Testosterone pellets can cause acne, hair growth and voice changes
- They aren't FDA-approved for menopause, and are rarely covered
Bioidentical, tested, and covered by insurance.
Most new patients are seen within a week, in person in Bridgewater or Nutley, or by video anywhere in New Jersey.
What about saliva testing?
Compounding practices often recommend saliva hormone tests to "customize" a formula. Saliva levels vary a great deal through the day and from one sample to the next, and they don't reliably reflect what's in your blood or tissues. We dose hormone therapy by how you feel and respond, and use blood tests where they genuinely help, for example when monitoring testosterone.
When compounding makes sense
There are a few good reasons to use a compounded product: an allergy to an ingredient found in every approved version, or a dose or form that simply isn't made commercially. In those cases we'll discuss it openly. For everyone else, FDA-approved bioidentical options give you the same hormones with more reliable quality and lower cost.
Keep reading
Bioidentical hormone questions
What are bioidentical hormones?
Bioidentical hormones have the same chemical structure as the hormones your body makes. Estradiol and micronized progesterone are bioidentical, and both are available as FDA-approved products, including patches, gels, pills and capsules.
Are bioidentical hormones safer than regular HRT?
Not simply because they're called bioidentical. FDA-approved bioidentical estradiol and progesterone are a good choice for many women, but custom-compounded versions haven't been shown to be safer or more effective, and their dose and purity aren't regulated in the same way.
What's wrong with hormone pellets?
Pellets are implanted under the skin and release hormones over months. They can't be removed if you have side effects, they often produce hormone levels well above the normal range, and they aren't FDA-approved for menopause. Most menopause experts recommend against them.
Is saliva testing needed to dose hormones?
No. Saliva hormone levels vary widely and don't reliably reflect what's in your blood or tissues. We dose hormone therapy based on your symptoms and response, with blood tests only where they're useful.
Are compounded hormones ever the right choice?
Occasionally, for example if you're allergic to an ingredient in every approved product, or need a dose that isn't commercially available. For most women, FDA-approved options work well and are covered by insurance.
Does insurance cover bioidentical hormones?
FDA-approved bioidentical estradiol and micronized progesterone are covered by most plans, including Medicaid. Compounded hormones and pellets are usually not covered and are often paid out of pocket.
- National Academies of Sciences, Engineering, and Medicine. The Clinical Utility of Compounded Bioidentical Hormone Therapy: A Review of Safety, Effectiveness, and Use. 2020.
- The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause 2022;29(7):767–794.
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