What’s the Difference Between HRT and BHRT?

Key Takeaways

• HRT and BHRT both ease menopause symptoms by replacing declining hormones.

• Traditional, older HRT options use synthetic or animal-derived hormones, while BHRT uses plant-based, bioidentical ones.

• There are several FDA-approved bioidentical options available, including estradiol and micronized progesterone. 

• Compounded BHRT is custom-made and not FDA-approved, so safety and effectiveness can vary.

As you transition into menopause, a period called perimenopause, your ovaries begin to produce less estrogen and progesterone.

This natural decline in hormone levels is what leads to many of the frustrating symptoms that we associate with menopause, such as hot flashes, night sweats, vaginal dryness, and mood swings.

Hormone replacement therapy (HRT) is one way to help manage menopausal symptoms. You may have also heard of bioidentical hormone replacement therapy (BHRT), a type of HRT that uses supplemental hormones chemically identical to the hormones your body produces naturally. 

But what is BHRT? And is it safer or more effective than HRT? We’ve got answers! Keep reading below as we discuss HRT and BHRT.

HRT works by replacing declining hormones, helping to alleviate the symptoms of perimenopause and menopause. When a provider prescribes HRT therapy for menopause, they may prescribe either estrogen alone or estrogen combined with a form of progesterone. Increasingly, they are also adding testosterone when necessary.

Traditional HRT primarily relied on synthetic hormones or hormones derived from animal sources. These hormones are very similar, but not identical, to the estrogen and progesterone made naturally by your ovaries. However, they still work to closely mimic the effects of naturally occurring hormones.

Synthetic forms of progesterone, known as progestins, are still commonly used in HRT and in birth control formulations. Animal-derived and synthetic estrogens, like conjugated equine estrogen, have largely fallen out of favor because they carry a slightly higher risk of stroke than bioidentical formulations. 

There are still many different types of traditional HRT that are FDA-approved to help with menopause symptoms, and they’re available in a variety of different forms.

Traditional HRT can be administered as a pill, tablet, skin patch, or gel. This is called systemic HRT, meaning that it enters your bloodstream and travels throughout your body.

If vaginal dryness is the only menopausal symptom you’re dealing with, low-dose estrogen formulations are available. These are often in the form of a cream or vaginal ring. This is called local or localized HRT, meaning it’s delivered to one specific area of your body.

Benefits of HRT

The evidence-supported benefits of HRT (whether synthetic or bioidnetical) include: 

• Reduced vasomotor symptoms. Up to 80 percent of women experience vasomotor symptoms like hot flashes and night sweats during perimenopause, with many rating these symptoms as moderate to severe. HRT can reduce the frequency of these bothersome symptoms by around 75 percent.

• Less vaginal dryness. HRT can also help to improve vaginal dryness, helping to increase sexual function and pleasure.

• Better mood and sleep. Menopause and perimenopause can also affect mood and sleep quality. There’s some evidence to support HRT’s ability to help address mood changes and poor sleep in women during this time.

• Stronger bones. Osteoporosis affects one in five women over age 50 and can lead to potentially serious fractures. HRT helps to slow bone loss associated with menopause, meaning you have a lower risk of osteoporosis and bone breaks.

• Lower all-cause mortality. When women start HRT before 60 years of age or within 10 years of the onset of menopause.

There’s a lot of confusion about what the term BHRT refers to. Many people mistakenly believe that the term bioidentical hormone therapy only refers to compounded hormone treatments. But there are actually several FDA-approved types of BHRT that are now commonly prescribed for menopause treatment. 

FDA-approved BHRT includes:

• Estradiol. Estradiol is identical to the estrogen your body produces during the reproductive years. 

• Micronized progesterone. This is a form of progesterone, identical to the kind your body makes, that’s easily absorbed into the bloodstream.  

BHRT typically uses plant-based hormones that are chemically similar or have an identical molecular structure to the estrogen and progesterone made in the human body.

The hormones used for BHRT are most often derived from yams, a root vegetable similar to a sweet potato.

We’ll explain this all in depth below. But here are the key differences between traditional HRT and bioidentical HRT. 

While some formulations of BHRT, such as those approved by the FDA, come in standardized forms, others are custom-made for individual patients. 

Compounded BHRT preparations are made in compounding pharmacies. Like other compounded medications, compounded BHRT isn't FDA-approved.

Compounded BHRT has become quite popular in recent years. Millions of people in the United States report using some form of compounded hormone therapy.

Compounded BHRT comes in a wide variety of forms, including pills, tablets, injectables, and suppositories.

Due to its plant-based sources, identical chemical structure, and customized dosing, bioidentical hormone therapy is often marketed as a more “natural” alternative to traditional hormone therapies. But this fails to account for the fact that there are FDA-approved formulations of bioidentical hormones available. 

There is currently no evidence available that supports claims that compounded BHRT is safer or more effective than other types of HRT.

 While compounded BHRT is often marketed as similarly or more effective than FDA-approved HRT, there’s actually no evidence supporting this.

 In fact, most of what we know about hormone therapy outcomes is based on research into traditional HRT. So does compounded BHRT offer the same benefits as FDA-approved HRT? It’s still unclear.

 Overall, more studies are needed to see how compounded BHRT stacks up against other types of HRT. A 2020 review concluded there was not yet sufficient evidence to determine the effectiveness of compounded BHRT in comparison with FDA-approved HRT. 

 Another claim that’s often made about compounded BHRT is that, due to its “natural” origins, it’s a safer treatment option with fewer side effects than other types of HRT.

However, there is currently little evidence to support this claim. The NASEM review found there was not enough evidence to determine the safety of compounded BHRT. What we know about safety and side effects of BHRT mostly comes from research into FDA-approved versions.

So what do you need to know about the safety of HRT in general?

Health risks associated with HRT can differ based on the type of hormone therapy you’re receiving. For example, combined HRT is associated with a slightly increased risk of breast cancer (though new analyses are calling this into question), while estrogen-only HRT is actually linked to a lower risk of breast cancer.

According to the American College of Obstetricians and Gynecologists (ACOG), HRT use is linked to a slightly increased risk of:

• Heart attack in women using combined HRT

• Blood clots and stroke with either type of HRT

• Breast cancer in women using combined HRT (note: some research is beginning to question this risk)

• Endometrial cancer in those taking estrogen-only HRT

• Gallbladder disease with either type of HRT

However, one of the main safety concerns about compounded BHRT has to do with the fact that compounded drugs are not approved by the FDA.

This means that, unlike FDA-approved hormone therapies, compounded BHRT isn’t rigorously tested for safety and effectiveness before it’s sold to you. 

Generally speaking, experts recommend sticking with FDA-approved hormone therapies. For example, an ACOG clinical consensus states that compounded BHRT should not be used when FDA-approved formulations are available. 

If all this talk of HRT, BHRT, and compounded BHRT has you tied up in knots, know that there are nonhormonal treatment options available for menopause symptoms.

For example, the FDA has approved four nonhormonal treatments for menopause symptoms. Some focus on reducing the frequency of vasomotor symptoms, while others address vaginal dryness or reduce the risk of osteoporosis and breast cancer in postmenopausal women.

The North American Menopause Society also recommends nonhormonal treatments like gabapentin or oxybutynin prescribed off-label for vasomotor symptoms and cognitive behavioral therapy for mood changes and sleep problems.

Perimenopause and menopause can significantly affect well-being and quality of life. Because of this, it’s important to seek care for troublesome symptoms. One option is some form of hormone therapy.

When it comes to HRT vs. BHRT, here’s what’s important to know: 

• Traditional HRT typically uses synthetic hormones or those derived from animals to mimic how natural hormones like estrogen and progesterone act in your body.

• Bioidentical HRT uses plant-derived hormones that are similar or identical in structure to the estrogen and progesterone made by the human body.

• Compounded BHRT is custom-made in a compounding pharmacy based on a person’s hormonal needs.

• There are standardized FDA-approved formulations of both traditional HRT and BHRT. Compounded BHRT is not FDA-approved.

 If you’re looking for a way to kick menopause symptoms to the curb, seek medical advice from a healthcare provider like your OB-GYN.

Hormone therapy needs to be tailored to your individual needs. A healthcare provider can look at factors like your age, symptoms, and history of other health conditions to help set up a treatment plan that works for you.