An In-Depth Look At Your Hormone Options

Hormones have been used for many different purposes for many years--prescribers may use them for various reasons, including weight loss, libido, birth control, menstrual regulation, fertility, mental health, sexual function, perimenopause & menopause, insomnia, growth, transgender care and more.

Menopausal hormone therapy is the term used to describe the two hormones, estrogen, testosterone and progestin, that are given to relieve bothersome symptoms of menopause. Estrogen is the primary hormone that relieves the symptoms. Those with a uterus must also take progestin (a progesterone-like hormone) to prevent uterine cancer. This is because estrogen alone can cause the lining of the uterus to overgrow (potentially leading to uterine cancer). Those who have had their uterus removed (hysterectomy) are not at risk for developing uterine cancer and can use estrogen alone.

Transgender hormone therapy is the term used to describe using estrogen, progesterone or testosterone to achieve feminizing or masculinizing characteristics. Feminizing hormone therapy is used to induce physical changes in your body caused by female hormones during puberty (secondary sex characteristics) to promote the matching of your gender identity and your body (gender congruence). If feminizing hormone therapy is started before the changes of male puberty begin, male secondary sex characteristics, such as increased body hair and changes in voice pitch, can be avoided. Feminizing hormone therapy is also known as gender-affirming hormone therapy.

Masculinizing hormone therapy is used to induce the physical changes in your body caused by male hormones during puberty (secondary sex characteristics) to promote the matching of your gender identity and body (gender congruence). If masculinizing hormone therapy is started before the changes of female puberty begins, female secondary sex characteristics, such as the development of breasts, can be avoided. Masculinizing hormone therapy is also known as gender-affirming hormone therapy.

Hormones are also used for birth control and/or menstrual regulation. Read our entire blog on your options for this purpose here ***

Regardless of your purpose for using hormones, it is helpful to understand the safest routes to take those hormones (patch, pill, injection, etc) and precautions to take as well as side effects and adverse (dangerous) effects that may occur.

What are my hormone options?

Your options will vary according to your medical health, your finances, and your goals. Hormone options usually include estrogen, testosterone, and progesterone, though some providers prescribe additional hormones. The categories of hormones gets broken down into bioidentical versus synthetic, and FDA-approved versus non-FDA-approved.

FDA-Approved Hormone therapy

Numerous FDA-approved hormone preparations are available for the treatment of menopausal symptoms, gender-affirming therapy, birth control, and menstrual regulation. These include those that fulfill the definition of bioidentical and those that are clearly not bioidentical. Products can contain only estrogen (synthetic conjugated estrogens; natural, nonhuman conjugated estrogens; or plant-derived bioidentical estrogens), only progestogens (synthetic progestin or bioidentical progesterone), or a combination of estrogen and progestin. Those that contain synthetic conjugated estrogens, conjugated estrogens (derived from the urine of pregnant mares), or progestins are not bioidentical to the endogenous human sex steroid hormones.

FDA-Approved Bioidentical therapy (BHT)

Currently, FDA-approved products containing bioidentical estrogen and progesterone are available. Bioidentical estrogen derived from plant sources (17β-estradiol) is available in pills, patches, sprays, creams, gels, and vaginal tablets. These preparations differ from custom compounded (CBHT) preparations in that they are carefully controlled and regulated formulations (eg, oral, transdermal, and vaginal preparations), they are manufactured under strict standards, and their effects are subjected to scientific scrutiny.

Numerous peer-reviewed publications have documented the beneficial effects of various doses of FDA-approved estrogen products on vasomotor symptoms, hot flashes, bone density, urogenital atrophy, and fracture prevention.

Both the FDA-approved and compounded hormones come in a variety of doses and routes of delivery (pills, creams, gels, sprays, and vaginal inserts).

In contrast, large-scale, randomized, controlled studies have not been conducted for custom bioidentical hormones (meaning, hormones from a compounding pharmacy). That being said, CBHT is very common method of delivery for hormones.

Compounded Custom Bioidentical Hormones

The term custom bioidentical hormones (CBHT) refers to hormone preparations that (1) have exactly the same chemical and molecular structure as the estrogens and progesterone produced within the human body, (2) are plant derived, and (3) are specifically compounded for an individual patient. Custom CBHT is not FDA-approved for treatment of menopausal symptoms which is why it is not covered by insurance.

The FDA defines compounding as: “the combining or altering of ingredients by a pharmacist, in response to a licensed practitioner's prescription, to produce a drug tailored to an individual patient's special medical needs”.

The most common compounded hormones include combinations of the endogenous estrogens (17β-estradiol, estrone, estriol) and progesterone.

Custom CBHT is available only at select pharmacies. Proponents of custom CBHT preparations believe they offer improved safety, efficacy, and tolerability because of the individualization of the formulas, the source of the hormones, and the routes of delivery.

Bioidentical testosterone is currently not FDA approved or commercially available for cis women. Through compounding pharmacy technology, the product can be formulated for off-label use, but again, will not be covered by insurance. Two gels are approved in the U.S. for cis men only: AndroGel and Testim (1%). There are no FDA approved products for cis women. However, many prescribers will prescribe testosterone to cis women. Since the commercially available dosages are too strong for cis women, testosterone compounded at a dosage of 0.5 to 2 mg per day is typically used for cis women wanting to slightly increase their levels (or a very small amount of Androgel can also be used). The dose is much higher for transgender purposes.

Transdermal testosterone appears to be the safest route. When taken orally, there is extensive first-pass metabolism in the liver that increases risks, including increases in cholesterol and risk for blood clots. Other risks include acne, male pattern hair loss and growth, along a long list of potential side effects.

Bioidentical progesterone is FDA approved, available commercially as a capsule of micronized progesterone in peanut oil. The micronization process allows the hormone to be better absorbed, but does not change the basic molecular structure of the hormone. For those allergic to peanut oil, it is possible to formulate progesterone in olive oil through compounding pharmacy technology. Bioidentical progesterone is also available as vaginal progesterone gel. If one has a uterus and are taking estrogen, they must take progesterone to protect themselves against endometrial cancer, which can happen when the uterus is exposed to estrogen without progesterone (we call this "unopposed estrogen").

Estrogen patch: Minivelle and Vivelle Dot are two brand name bioidentical estradiol patches, available in a range of dosages.

**The dose of estrogen in a patch is not equivalent to the dose in a pill, so if you changing from pill to patch or vice versa, know that your dose may look very different. The dose for menopausal therapy vs birth control vs transgender therapy will be very different.

Patches should be placed on the lower abdomen and changed once or twice weekly, per prescription order, providing steady levels of estrogen throughout the day and night.

The patch sticks to the skin, even with showering, swimming, or sweating. The adhesive may cause skin irritation for some. The adhesive can be removed with rubbing alcohol or sometimes oil.

Estrogen Gel:

Estrogel, Elestrin, and Divigel are brand names of bioidentical estradiol gels to be used topically. The gel is supplied in a pump dispenser or in foil packets, and should be rubbed into the skin of the inner arm daily. Your dose may be one, two, or three pumps gel per day (or the contents of one foil packet per day). Your dose will of course depend on the purpose for which it is being prescribed.

Estrogen Spray:

Evamist is the brand name of a bioidentical estradiol spray. It is sprayed onto the soft skin of the inner forearm and dries quickly – no rubbing-in is required. Your dose may be one, two, or three sprays daily, sometimes more, depending on the purpose prescribed.

Estrogen Cream:

This can be produced in a compounding pharmacy in any dose needed. The bioidentical estradiol cream is supplied in a specialized dispenser, called a topiclick. The dispenser has a dial on the bottom and a hole in the top, through which a measured dose is delivered when the bottom is twisted. The cream is low volume, non-greasy or smelly, and easy to rub into the arms or legs for daily