Compounded & Bioidentical HRT: The Complete HRT Guide

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Overview / What Is Compounded & Bioidentical HRT?

The Basics

If you have been researching hormone therapy for menopause, you have almost certainly encountered the terms "bioidentical" and "compounded." These words appear everywhere, from social media to clinic marketing materials to well-meaning advice from friends. The problem is that they are frequently used interchangeably, creating confusion about what they actually mean and whether one type of hormone therapy is inherently better or safer than another.

Here is the core distinction, and it matters enormously for your health decisions:

Bioidentical simply means that the hormone is chemically identical to the hormones your body produces naturally. Estradiol is bioidentical. Micronized progesterone is bioidentical. Many of the most commonly prescribed, FDA-approved hormone therapy products on the market today are bioidentical. Estradiol patches (Climara, Vivelle-Dot), estradiol gels (EstroGel, Divigel), and oral micronized progesterone (Prometrium) are all bioidentical hormones that have been thoroughly tested for safety, efficacy, and quality. The word "bioidentical" does not mean "compounded," "special," or "only available from a specialty pharmacy."

Compounded means that the preparation was custom-mixed by a compounding pharmacy, typically based on an individual prescriber's order. Compounded hormone preparations have not been reviewed by the FDA for safety, effectiveness, or quality. They are not subject to the same rigorous manufacturing standards as FDA-approved products. This does not mean they never work, but it does mean the evidence supporting their use is far more limited, and the quality control guarantees that protect patients are absent.

The marketing of compounded hormone therapy has blurred this distinction for decades. Compounded products are frequently marketed as "bioidentical" to imply they are more natural, personalized, and safer than "synthetic" alternatives. In reality, many FDA-approved products already are bioidentical, and the major medical organizations that specialize in menopause care (including The Menopause Society, ACOG, the Endocrine Society, and the FDA) have concluded that there is no evidence compounded bioidentical hormones are safer or more effective than their FDA-approved counterparts.

This guide will walk you through what the evidence actually says, when compounding may make medical sense, what the risks are, and how to make informed decisions with your healthcare provider.

The Science

The term "bioidentical" entered widespread use not as a scientific designation but as a marketing construct, adopted by compounding pharmacies and alternative medicine practitioners in the late 1990s and early 2000s to differentiate their products from conventional hormone therapy [1]. The Endocrine Society's 2016 Scientific Statement (Santoro et al., JCEM 2016;101:1318-43) notes that "bioidentical" has no standardized pharmacological definition and that any hormone can be manufactured to be structurally identical to endogenous human hormones [1].

From a biochemical standpoint, 17-beta estradiol prescribed as an FDA-approved transdermal patch is molecularly identical to 17-beta estradiol dispensed as a compounded sublingual troche or topical cream. The difference lies not in the hormone itself but in the manufacturing oversight, quality assurance, and evidence base supporting each formulation. FDA-approved products undergo rigorous bioequivalence testing, pharmacokinetic characterization, and clinical trials demonstrating safety and efficacy under 21 CFR regulatory frameworks [2]. Compounded preparations are exempt from these requirements under Section 503A of the Federal Food, Drug, and Cosmetic Act [3].

The National Academies of Sciences, Engineering, and Medicine (NASEM), in a 352-page consensus report commissioned by the FDA (2020), concluded that there is insufficient evidence to support the clinical utility of compounded bioidentical hormone therapy, and that claims of clinical utility are not substantiated by evidence from well-designed studies [4]. An estimated 1 to 2.5 million women in the United States use compounded bioidentical hormone preparations [5].

Medical / Chemical Identity

Estriol: A Special Note

Estriol (E3) is a key ingredient in many compounded formulations (Biest, Triest) but has no FDA-approved drug product. The FDA has stated it does not have evidence that estriol is safe and effective, or that it is a "safer form of estrogen" [6]. Estriol has approximately one-third the receptor-binding affinity of estradiol and preferentially activates certain estrogen receptor pathways. Its inclusion in compounded formulations is based on the theory that it provides a "gentler" estrogen effect, but this claim has not been validated in well-designed clinical trials.

Mechanism of Action / Pathophysiology

The Basics

The hormones in compounded preparations work in the same fundamental ways as the hormones in FDA-approved products, because they are the same molecules. Estradiol, whether it comes from a compounding pharmacy or a major pharmaceutical manufacturer, binds to the same estrogen receptors in your body and triggers the same biological responses. Progesterone from a compounding pharmacy and progesterone from an FDA-approved capsule activate the same progesterone receptors.

This is actually the central point that professional medical organizations make when discussing compounded versus FDA-approved hormone therapy: if the active hormone is the same, the therapeutic effects should be the same. The differences lie in quality control, consistency, and the evidence base, not in how the hormones work in your body.

Where compounded formulations differ is in the combinations and delivery methods they offer. Biest, for example, combines estradiol with estriol in specific ratios, while no FDA-approved product offers this combination. Whether these combinations offer clinical advantages over single-hormone FDA-approved products remains unproven in rigorous clinical trials.

The Science

The pharmacological mechanism of action for bioidentical hormones is independent of their manufacturing source. 17-beta estradiol binds to estrogen receptors alpha (ER-alpha) and beta (ER-beta) with identical affinity regardless of whether it is dispensed from an FDA-approved product or a compounding pharmacy [7]. Micronized progesterone binds to progesterone receptors PR-A and PR-B through the same genomic and non-genomic signaling pathways in both contexts [8].

The mechanistic question unique to compounded HRT concerns formulations containing estriol. Estriol (E3) has approximately one-third the binding affinity for ER-alpha compared to estradiol and demonstrates preferential ER-beta agonism in some tissue contexts [9]. Proponents of Biest (80% estriol / 20% estradiol) argue this provides a "safer" estrogenic profile by reducing ER-alpha-mediated proliferative signaling in breast tissue. However, the NASEM committee found no well-designed clinical studies supporting claims that estriol-containing combinations are safer or more effective than estradiol alone [4]. The Endocrine Society has noted that the theory of estriol as a "protective" estrogen lacks adequate evidentiary support [1].

Pathway & System Visualization

Pharmacokinetics / Hormone Physiology

The Basics

How a hormone gets into your body matters just as much as what the hormone is. This is where compounded and FDA-approved hormone therapy can diverge in meaningful ways, even when the active hormone is identical.

FDA-approved hormone products have undergone extensive pharmacokinetic testing, which means researchers have carefully measured how quickly the hormone is absorbed, how much reaches your bloodstream, how long it stays in your system, and how consistently it performs from dose to dose and batch to batch. When your doctor prescribes an estradiol patch, there is a wealth of data predicting what your blood levels will be and how reliably the product will perform.

Compounded formulations, by contrast, have not undergone this testing. The absorption characteristics of a compounded cream depend on the specific base used, the concentration of the active ingredient, and the compounding process, all of which can vary between pharmacies and even between batches from the same pharmacy. A study of 13 compounding pharmacies found that estradiol levels could be up to 26% below the label claim and progesterone up to 31% above, meaning you may be getting meaningfully more or less hormone than intended.

This variability has real clinical implications. If your progesterone level is too low, your endometrium may not be adequately protected against estrogen-stimulated growth. If your estradiol level is higher than expected, you may experience more side effects. The consistency that comes with FDA-approved manufacturing directly impacts the predictability and safety of your treatment.

The Science

The pharmacokinetic variability of compounded preparations represents one of the strongest evidence-based arguments for preferring FDA-approved formulations when they exist. Stanczyk et al. (Menopause 2019;26:966-71) analyzed compounded estradiol/progesterone capsules and creams from 13 compounding pharmacies and found the majority were within 10% of the label claim, but individual products deviated by as much as 26% below label for estradiol and 31% above label for progesterone [10].

For transdermal compounded preparations specifically, absorption is highly dependent on the vehicle (cream vs gel vs ointment), the concentration of the active ingredient, the application site, and the skin characteristics of the individual patient. Unlike FDA-approved transdermal products (which undergo formal bioavailability and bioequivalence studies under 21 CFR 320), compounded topical preparations have no standardized pharmacokinetic data [4][11].

Compounded sublingual troches achieve rapid absorption through the oral mucosa, bypassing first-pass hepatic metabolism. However, swallowed portions undergo hepatic first-pass metabolism, creating a mixed pharmacokinetic profile that is difficult to predict or standardize [4].

Subcutaneous pellet implants provide sustained hormone release over 3-6 months. Pharmacokinetic profiles with pellets can be unpredictable, with initial supraphysiologic spikes followed by declining levels. Unlike patches, gels, or oral products, pellets cannot be removed if adverse effects occur, creating an inherent safety limitation [11][12].

Research & Clinical Evidence

The Basics

What does the research say about compounded bioidentical HRT?

The honest answer is: not enough. This is not a matter of one study saying it works and another saying it does not. The fundamental problem is that the kind of rigorous, large-scale, long-term clinical trials that would allow us to confidently evaluate compounded HRT simply have not been conducted. Every major review of the evidence, from the NASEM 2020 consensus report to the ACOG 2023 Clinical Consensus to systematic reviews in peer-reviewed journals, arrives at the same conclusion: the data are insufficient.

This does not mean compounded HRT does not work. The active hormones it contains (estradiol, progesterone, testosterone) are well-studied individually in FDA-approved forms and are proven effective for menopause symptoms. The question is whether the compounded delivery of these hormones offers any advantages, and whether the lack of quality control introduces risks that outweigh any benefits.

What do the reviews actually find?

The most comprehensive systematic review to date (Liu et al., Menopause 2022) analyzed 29 randomized controlled trials involving 1,808 women. The review found that compounded bioidentical HRT was not associated with adverse changes in lipid profiles or glucose metabolism in short-term use. But the key finding was about what the data could not tell us: there were no RCT data available to assess the risk of breast cancer, endometrial cancer, or cardiovascular disease with compounded preparations. The longest study was only one year. For outcomes that may take years or decades to manifest, this evidence gap is significant.

Does compounded HRT have unique benefits?

The one area where compounded formulations show a specific benefit is vaginal testosterone and DHEA for vaginal atrophy. The Liu et al. review found a significant improvement in vaginal atrophy symptoms with compounded vaginal androgens compared to placebo. Compounded testosterone is also used for sexual interest and arousal disorders in postmenopausal women, and there is reasonable evidence supporting this use, though no FDA-approved testosterone product for women exists.

The Science

The 2020 NASEM consensus report reviewed the available evidence and concluded that claims of clinical utility for compounded bioidentical HRT are not substantiated by evidence from well-designed or properly controlled clinical studies. The committee found that most information about the safety and effectiveness of cBHT came from low-quality data: anecdotal claims, patient reports, and prescriber testimonies [4].

Liu et al. (Menopause 2022;29:465-82) conducted a systematic review and meta-analysis of 29 RCTs (n=1,808). Key findings:

• Lipid profile and glucose metabolism: No adverse changes associated with cBHT (short-term use)
• Endometrial thickness: No significant difference between cBHT and placebo or FDA-approved products (studies up to 1 year)
• Androgenic effects: Compounded DHEA was associated with higher risk of androgenic effects vs placebo (RR 3.87, 95% CI 1.28-11.65)
• Vaginal atrophy: Compounded vaginal testosterone/DHEA showed significant improvement vs placebo (SMD -0.66, 95% CI -1.28 to -0.04)
• Sexual function: Combining vaginal testosterone/DHEA subgroups demonstrated significant improvements in arousal, lubrication, satisfaction, pain, and FSFI score vs placebo
• Critical gap: No RCT data available to assess clinical risk of breast cancer, endometrial cancer, or cardiovascular disease [13]

A 2004 Cochrane Review of menopausal HRT noted a 57.7% reduction in hot flushes within the placebo group alone, demonstrating the necessity of placebo-controlled trials for evaluating any HRT product's efficacy [14].

The Endocrine Society Scientific Statement (Santoro et al., JCEM 2016) reviewed the pharmacology and physiology of popular compounded hormones and found no evidence supporting the notion that custom-compounded bioidentical hormones have fewer risks compared with FDA-approved treatments [1].

Evidence & Effectiveness Matrix

Categories not scored (insufficient data): Anxiety & Stress Response, Bone Health & Osteoporosis, Cardiovascular Health, Metabolic Health & Insulin Sensitivity, Joint & Musculoskeletal Health, Headache & Migraine, Endometrial Safety, Menstrual & Reproductive, Other Physical Symptoms

Benefits & Therapeutic Effects

The Basics

The benefits of compounded bioidentical HRT are, in most cases, the benefits of the hormones themselves, not of the compounding process. When compounded estradiol relieves hot flashes, that is estradiol working, not a special property of the compounding. When compounded progesterone helps with sleep, that is micronized progesterone's known sedative properties at work.

That said, compounded formulations do offer some practical advantages that matter to certain patients:

Dosing flexibility. Compounding pharmacies can create doses that are not commercially available. If you need a specific dose of estradiol that falls between available FDA-approved options, a compounding pharmacy can fill that prescription.

Allergen avoidance. If you are allergic to an ingredient in an FDA-approved product (for example, the peanut oil in branded Prometrium), a compounding pharmacy can prepare the same hormone without the offending ingredient.

Testosterone access for women. This is perhaps the most important legitimate use case. No FDA-approved testosterone product exists for cisgender women. Compounded testosterone (cream, gel, or other forms) is the primary way women access testosterone therapy for sexual interest and arousal disorders and other menopause-related symptoms.

Delivery form variety. Compounding pharmacies offer delivery forms not available commercially, such as sublingual troches, vaginal suppositories, and subcutaneous pellets. Some patients find these forms more convenient or better tolerated.

The Science

The ACOG Clinical Consensus No. 6 (2023, Reaffirmed 2026) identifies two legitimate indications for compounded HRT: (1) patient allergy to an ingredient in an FDA-approved product, and (2) need for a specific dosage or delivery format not available in FDA-approved products [11].

For testosterone therapy in postmenopausal women, ACOG recognizes that short-term use of transdermal testosterone can be considered for sexual interest and arousal disorders, noting that there is currently no FDA-approved testosterone formulation for cisgender women [11]. The 2019 Global Consensus Position Statement on testosterone therapy for women (Davis et al., JCEM 2019;104:4660-6) recommends testosterone therapy for postmenopausal women with HSDD after appropriate counseling about risks and unknown long-term effects [15].

The Liu et al. (2022) meta-analysis found that compounded vaginal androgen therapy (testosterone and DHEA) significantly improved vaginal atrophy symptoms and Female Sexual Function Index scores compared to placebo [13]. Dosages in the studies were highly variable (300 micrograms to 5 mg) and treatment duration ranged from 1 month to 6 months.

Risks, Side Effects & Safety

The Basics

Every form of hormone therapy carries some level of risk, and compounded bioidentical HRT is no exception. The key concern with compounded products is not that the hormones themselves are more dangerous but that the lack of regulatory oversight introduces additional, avoidable risks on top of the inherent risks of hormone therapy.

Risks shared with all HRT (estrogen + progestogen therapy):

These risks apply whether you use FDA-approved or compounded products, because the active hormones are the same:

• Venous thromboembolism (VTE): Oral estrogen increases VTE risk. The WHI reported approximately 18 additional VTE events per 10,000 women per year with oral conjugated equine estrogens (HR 2.06, 95% CI 1.57-2.70). Transdermal estrogen does not appear to significantly increase VTE risk (ESTHER study: adjusted OR 0.9, 95% CI 0.4-2.1). This route-dependent difference applies equally to compounded and FDA-approved oral estrogen.
• Breast cancer: Combined estrogen-progestogen therapy was associated with 8 additional breast cancer cases per 10,000 women per year in the WHI (HR 1.26, 95% CI 1.00-1.59). Estrogen-alone therapy showed no significant increase (HR 0.77, 95% CI 0.59-1.01). The E3N French cohort study found no significant increase with estrogen plus micronized progesterone (HR 1.00, 95% CI 0.83-1.22) compared to a significant increase with estrogen plus synthetic progestins (HR 1.69, 95% CI 1.50-1.91). There is no evidence that compounded formulations alter these risk profiles.
• Stroke: Dose-dependent and route-dependent. Lower doses and transdermal routes carry lower risk.
• Endometrial cancer: Unopposed estrogen increases endometrial cancer risk. Adequate progesterone opposition is mandatory for women with an intact uterus.

Risks specific to compounded HRT:

• Dosing inconsistency: Studies have found compounded products can deviate significantly from their labeled dose, with estradiol up to 26% below and progesterone up to 31% above the intended amount. Underdosed progesterone is a serious safety concern for women with a uterus, as it may fail to protect against endometrial hyperplasia and cancer.
• No quality assurance: Compounded products are not subject to current Good Manufacturing Practice (cGMP) standards. Purity, potency, and sterility are not independently verified.
• No adverse event reporting requirement: Compounding pharmacies under Section 503A are not required to report adverse events to the FDA. This means safety signals cannot be tracked systematically.
• No labeling with risk information: Compounded products do not carry the standardized warnings, contraindications, and side effect information that accompany FDA-approved products.
• Contamination risk: Compounded preparations carry the potential for bacterial contamination, as documented in broader compounding pharmacy investigations.

Risks specific to compounded testosterone:

• Androgenic side effects: Hirsutism, acne, voice deepening (potentially irreversible), hair thinning/loss
• Supraphysiologic levels: Without standardized pharmacokinetic data, testosterone levels can exceed the physiologic premenopausal range (20-80 ng/dL)
• Breast cancer risk uncertainty: The long-term effects of testosterone on breast cancer risk are unknown. The Nurses' Health Study (2006) reported a 2.5-fold increased risk with estrogen plus testosterone therapy, though this used a formulation no longer available

Risks specific to pellet therapy:

• Cannot be removed: Once a pellet is implanted, it dissolves over 3-6 months and cannot be easily extracted if adverse effects occur
• Unpredictable pharmacokinetics: Initial supraphysiologic spikes followed by declining levels
• Insertion complications: Extrusion, cellulitis, bleeding (rates appear low but are not systematically tracked)
• High discontinuation: One study found 43% of patients discontinued after the first insertion
• ACOG position: ACOG recommends preparations other than pellet therapy for testosterone delivery based on lack of safety data and inability to remove the pellet

Being informed about potential risks is important. Being able to track and document any side effects you actually experience is what turns awareness into safety. Doserly lets you log side effects as they happen, with timestamps and severity ratings, so nothing falls through the cracks between appointments.

If you're experiencing breakthrough bleeding, headaches, breast tenderness, or any other change, having a documented timeline helps your provider distinguish between expected adjustment effects and signals that warrant a protocol change. The app also checks for interactions between your HRT and any other medications or supplements you're taking.

The Science

The 2022 ACOG Clinical Consensus documented specific quality control findings: Stanczyk et al. (Menopause 2019) evaluated estradiol/progesterone capsules and creams from 13 compounding pharmacies and found that while the majority were within 10% of label claim, individual products deviated by as much as 26% below label for estradiol and 31% above label for progesterone [10]. In a separate study, compounded DHEA was associated with a 3.87-fold increased risk of androgenic effects compared to placebo (95% CI 1.28-11.65) [13].

The NASEM 2020 report noted that there are no requirements for adverse event reporting from 503A compounding pharmacies, hindering definitive safety evaluation [4]. The Endocrine Society highlighted documented cases of patient harm associated with compounded treatments, including fungal contamination of compounded glucocorticoid preparations [1].

For pellet therapy specifically, a retrospective analysis of a proprietary compounded testosterone pellet product found 43% of patients discontinued therapy after the first insertion [11]. Reported complications from testosterone pellets include increases in facial hair, acne, perceived voice changes, mood swings, anxiety, weight gain, acute uterine bleeding, and hysterectomy secondary to abnormal uterine bleeding [11].

The long-term breast cancer risk with testosterone therapy remains unclear. A prospective 10-year cohort study of testosterone pellet users reported decreased breast cancer incidence compared to SEER historical controls, but the study was limited by inclusion of premenopausal and postmenopausal women, addition of anastrozole to 62% of pellets midway through the study, significant loss to follow-up (1,267 to 407), and use of a historical control group [16].

Dosing & Treatment Protocols

The Basics

One of the primary marketing appeals of compounded HRT is the promise of "individualized" or "customized" dosing. The idea is that a compounding pharmacy can create a preparation tailored exactly to your needs, based on testing of your hormone levels. This sounds appealing, but there are important caveats.

First, most menopause specialists do not rely on hormone level testing to guide HRT dosing for standard menopause treatment. The primary goal of HRT is symptom relief, and dosing is typically guided by how you feel, not by hitting a specific number on a blood test. Salivary hormone testing, often promoted by providers who prescribe compounded HRT, does not offer accurate or precise assessment of hormone levels and is not recommended by ACOG, NAMS, or the Endocrine Society.

Second, FDA-approved products already come in a wide range of doses. Estradiol patches are available in 0.025 mg, 0.0375 mg, 0.05 mg, 0.075 mg, and 0.1 mg options. Oral estradiol comes in 0.5 mg, 1 mg, and 2 mg tablets. Micronized progesterone is available in 100 mg and 200 mg capsules. This range allows substantial dose customization within FDA-approved frameworks.

Third, compounding introduces a practical risk: you may not be getting the dose you think you are. The documented variability in compounded preparations means your "customized" dose may actually be less accurate than a mass-manufactured, quality-controlled product.

When compounded dosing makes sense:

• When a patient needs a specific dose not available commercially (genuinely rare with the current range of FDA-approved options)
• When a patient needs a combination not available commercially (such as estradiol + estriol in specific ratios)
• For testosterone therapy in women, where the only option is compounded or off-label use of male-dosed products

Getting the dosing right often takes time and fine-tuning with your provider. Keeping an accurate record of what you're actually taking, doses, timing, and any adjustments, makes that process smoother. Doserly tracks your HRT doses alongside everything else in your health stack, so your full protocol is always in one place.

Never wonder whether you took your morning dose or when you last changed your patch. The app logs every dose with a timestamp and sends reminders when your next one is due, helping you maintain the consistency that makes hormone therapy most effective.

The Science

The ACOG Clinical Consensus (2023) states that the primary goal of hormone therapy is to alleviate menopause-related symptoms, and that most individuals do not require additional ancillary testing of serum levels. Dosing should be titrated to patient-reported symptom relief [11].

ACOG further notes that salivary testing does not offer accurate or precise assessment of hormone levels. Estrogen levels are extremely low in saliva, making them methodologically challenging to measure. Progesterone is present at higher saliva levels, but circulating levels do not necessarily reflect tissue levels [11].

For patients already on compounded HRT, clinicians may consider serum level testing to verify adequate levels: a target estradiol level of 40-100 pg/mL is a reasonable range for symptom relief. For testosterone, levels should be maintained in the physiologic premenopausal range of 20-80 ng/dL, measured by liquid or gas chromatography and tandem mass spectrometry assays [11][15].

What to Expect (Timeline)

If you are starting compounded bioidentical HRT, the timeline of expected response is similar to FDA-approved HRT, since the active hormones are the same:

Days 1-7: Initial adjustment period. Some women notice breast tenderness, bloating, or spotting. With sublingual troches, you may notice a taste. With pellets, the insertion site may be tender.

Weeks 2-4: Hot flashes and night sweats often begin to improve. Sleep quality may start to improve as vasomotor symptoms decrease. Some women report mood improvements during this period.

Months 1-3: Vasomotor symptoms typically improve significantly. Mood stabilization continues. Vaginal dryness may start to improve, particularly with local estrogen or vaginal DHEA/testosterone. If you are on testosterone, libido changes may begin to be noticeable, though many women need 6-12 weeks.

Months 3-6: Full therapeutic effect for most symptoms. Bone density stabilization begins with systemic estrogen. Sexual function improvements with testosterone are typically evident by this point.

Ongoing maintenance: Regular follow-up with your provider every 3-6 months initially, then annually. Dose adjustments may be needed. For pellet users, new pellets are typically inserted every 3-6 months.

Important note about consistency: Because compounded preparations can vary between batches, you may notice fluctuations in how well your symptoms are controlled that would not occur with FDA-approved products. If your symptoms seem well-controlled for a few weeks and then return, discuss the possibility of batch variability with your provider and compounding pharmacy.

Timing Hypothesis & Window of Opportunity

The timing hypothesis applies to all systemic HRT, whether compounded or FDA-approved. The core principle is that HRT initiated within 10 years of menopause onset or before age 60 appears to have a more favorable risk-benefit profile than late initiation.

This concept is supported by age-stratified analyses of the WHI, the KEEPS trial (Kronos Early Estrogen Prevention Study), the ELITE trial (Early vs Late Intervention Trial with Estradiol), and the Danish Osteoporosis Prevention Study. Women who started HRT earlier showed evidence of cardiovascular benefit or neutrality, while women who started later (particularly over 10 years post-menopause) showed increased cardiovascular risk.

For compounded HRT specifically, these timing principles apply equally. No evidence suggests that compounded formulations alter the timing-dependent risk-benefit profile of hormone therapy. The active hormones are the same, so the biological interaction with vascular health and the healthy cell/damaged cell hypothesis remains unchanged.

If you are considering starting any form of HRT, including compounded, the timing of initiation relative to your menopause onset is an important factor to discuss with your provider.

Interactions & Compatibility

Interactions for compounded HRT are the same as for FDA-approved HRT containing the same hormones, since the active molecules are identical:

Drug-Drug Interactions:

• Thyroid medications: Estrogen increases thyroid-binding globulin (TBG), which may necessitate levothyroxine dose adjustment. Monitor TSH levels.
• CYP3A4 inducers (rifampin, carbamazepine, phenytoin, St. John's Wort): May reduce estrogen levels by accelerating hepatic metabolism. Particularly relevant for oral estrogen preparations.
• CYP3A4 inhibitors (ketoconazole, erythromycin, grapefruit juice): May increase estrogen levels.
• Lamotrigine: Estrogen significantly reduces lamotrigine levels, potentially worsening seizure control.
• Anticoagulants (warfarin): Estrogen may affect coagulation parameters. Monitor INR.

Supplement Interactions:

• St. John's Wort: CYP3A4 inducer; may reduce estrogen efficacy. See St. John's Wort guide.
• Black cohosh: No significant pharmacokinetic interaction with HRT; may be used adjunctively for vasomotor symptoms.
• Calcium and Vitamin D: Complementary for bone health alongside HRT.

Lifestyle Factors:

• Smoking: Dramatically increases VTE and cardiovascular risk with HRT, particularly oral estrogen. Transdermal estrogen partially mitigates the VTE risk but does not eliminate the cardiovascular risk associated with smoking.
• Alcohol: Moderate alcohol use may increase estrogen levels and breast cancer risk slightly.

Compounding-Specific Interaction Note:

Because compounded preparations may contain multiple hormones in a single formulation (e.g., Biest with progesterone and testosterone), drug interactions may be more complex. Practitioners and patients should ensure that all active ingredients in a compounded prescription are disclosed when checking for interactions. Unlike FDA-approved products, compounded preparations do not come with standardized drug interaction information.

Related HRT guides: Estradiol, Micronized Progesterone, DHEA/Prasterone, Biest, Triest

Decision-Making Framework

The decision to use compounded HRT versus FDA-approved HRT is not a medical decision that should be made based on marketing materials. It is a clinical decision that should be made in partnership with a knowledgeable healthcare provider, ideally one who is familiar with the full range of available options.

Questions to ask your provider:

1. "Is there an FDA-approved bioidentical hormone product that would work for my situation?" (The answer is often yes.)
2. "If you are recommending compounded HRT, what is the specific medical reason an FDA-approved product would not be appropriate for me?"
3. "How do you monitor for adequate dosing with compounded products?"
4. "Does this compounding pharmacy undergo third-party quality testing?"
5. "What are my options if I experience side effects on a compounded product versus an FDA-approved product?"
6. "Are you aware of the ACOG, NAMS, and Endocrine Society positions on compounded bioidentical HRT?"

Red flags in provider practices:

• Insistence on salivary hormone testing as the basis for prescribing
• Claims that compounded HRT is "safer" or "more natural" than FDA-approved HRT
• Selling compounded products directly from their office
• Recommending pellet therapy without discussing the inability to remove the pellet or the lack of safety data
• Dismissing FDA-approved bioidentical options as "synthetic"
• Framing the discussion as "big pharma" versus "natural medicine"

Finding a menopause specialist:

• NAMS Certified Menopause Practitioner directory: menopause.org
• ISSWSH (International Society for the Study of Women's Sexual Health) for sexual health concerns
• Telehealth menopause clinics that prescribe FDA-approved products (Midi Health, Alloy, Gennev, and others)

When compounding is the right choice:

• You have a documented allergy to an ingredient in available FDA-approved products
• You need a specific dose that is not commercially available
• You need testosterone therapy (no FDA-approved product for women)
• You need a delivery form not commercially available (e.g., vaginal progesterone suppository at a specific dose)

The best HRT decisions happen when you walk into your appointment prepared. Doserly helps you organize your symptom data, treatment history, and questions ahead of time, so you can make the most of your consultation time and ensure nothing important gets forgotten.

The app generates appointment-ready summaries of your recent symptom trends, current protocol, and any side effects you've logged. Instead of trying to recall three months of experience in a ten-minute appointment, you have a clear, organized record to share with your provider.

Administration & Practical Guide

If you are using compounded HRT, the practical considerations vary by delivery form:

Sublingual troches: Place under the tongue and allow to dissolve completely (usually 15-30 minutes). Avoid eating, drinking, or brushing teeth immediately before or after. The sublingual route bypasses liver first-pass metabolism, but any portion swallowed will undergo hepatic processing.

Topical creams and gels: Apply to clean, dry skin (inner arm, inner thigh, or behind the knee are common sites). Rotate application sites to reduce skin irritation. Allow to dry completely before dressing or contact with others. Wash hands after application. Avoid application to breast tissue. Be aware of transfer risk to children, pets, or partners through skin contact.

Vaginal suppositories and creams: Follow your provider's instructions for applicator use and timing. Typically applied at bedtime for best absorption and comfort.

Subcutaneous pellets: Inserted by a provider via a small incision, usually in the hip or buttock area. The site may be tender for a few days. Avoid vigorous exercise and submerging the site in water for 5-7 days post-insertion. Monitor for signs of extrusion (pellet working its way out) or infection at the insertion site.

Oral capsules: Take as directed, usually at bedtime (particularly for progesterone, which has sedative effects). Oral preparations undergo first-pass hepatic metabolism.

Storage: Compounded products may have different storage requirements than FDA-approved products. Follow the compounding pharmacy's instructions. Some may require refrigeration. Check expiration dates carefully, as compounded products may have shorter shelf lives.

This section provides general guidance only and does not replace the specific instructions from your prescriber and compounding pharmacy.

Monitoring & Lab Work

Pre-HRT baseline (applicable to all HRT, not just compounded):

• Hormone levels (FSH, estradiol) if diagnosis is uncertain
• Mammogram (current per national guidelines)
• Lipid panel
• Blood pressure
• Bone density (DEXA) if indicated
• Thyroid function (TSH, free T4)
• Pelvic ultrasound or endometrial assessment if abnormal bleeding present

Compounded HRT-specific monitoring:

If you are using compounded products, your provider may want to check serum hormone levels to verify that your dose is delivering the expected amount. This is not routine for FDA-approved products (where pharmacokinetics are well-established) but may be prudent for compounded preparations given documented dosing variability.

• Estradiol target range: 40-100 pg/mL is generally considered reasonable for symptom relief
• Testosterone target range: 20-80 ng/dL (physiologic premenopausal range). Measure using liquid chromatography-tandem mass spectrometry (LC-MS/MS) assays, as direct immunoassays are unreliable in the female range.
• DHEA-S: If using compounded DHEA, monitor for supraphysiologic levels

Ongoing monitoring schedule:

• 3-month review: Symptom assessment, side effect evaluation, dose adjustment. For pellet users, this coincides with re-insertion timing.
• 6-month review: Hormone level check (more relevant for compounded than FDA-approved), endometrial assessment if unexpected bleeding
• Annual review: Comprehensive reassessment including mammogram, lipid panel, bone density (if indicated), blood pressure, and discussion of continued benefits vs risks

Endometrial monitoring: Women with a uterus using any estrogen therapy must have adequate progesterone opposition. If using compounded progesterone (particularly topical cream), endometrial monitoring via transvaginal ultrasound or endometrial biopsy may be especially important, as topical progesterone absorption is unreliable and may not provide adequate protection.

Complementary Approaches & Lifestyle

Whether you use compounded or FDA-approved HRT, complementary strategies can enhance your overall wellbeing during the menopause transition:

Supplements with menopause evidence:

• Vitamin D: Essential for calcium absorption and bone health. Most menopause guidelines recommend 800-1000 IU daily minimum. See Vitamin D guide.
• Calcium: 1200 mg daily for postmenopausal women (from diet + supplements). See Calcium guide.
• Magnesium: May support sleep quality and muscle function. See Magnesium guide.
• Omega-3 fatty acids: Cardiovascular health support. See Omega-3 guide.

Exercise recommendations:

• Resistance training (2-3 sessions per week) for bone density and lean muscle preservation
• Cardiovascular exercise (150 minutes per week minimum)
• Balance training for fall prevention
• Yoga and tai chi for flexibility and stress management

Dietary approaches:

• Mediterranean diet pattern (associated with reduced cardiovascular risk and favorable body composition)
• Adequate protein (1.0-1.2 g/kg/day) for muscle preservation
• Phytoestrogen-rich foods (soy, flaxseed) may provide modest symptom relief for some women

Sleep hygiene:

• Cool bedroom temperature (particularly important for vasomotor symptoms)
• Consistent sleep and wake times
• CBT for insomnia (CBT-I) if sleep problems persist

Non-hormonal prescription alternatives:

For women who cannot or choose not to use HRT, non-hormonal options include fezolinetant (Veozah), paroxetine (Brisdelle), and gabapentin. See Non-Hormonal Menopause Treatments.

Stopping HRT / Discontinuation

The considerations for stopping compounded HRT are similar to those for FDA-approved HRT, with one important additional factor: if you are transitioning off compounded products, this may be an opportunity to discuss switching to FDA-approved alternatives rather than discontinuing hormone therapy entirely.

Tapering strategies:

• Gradual dose reduction over weeks to months is generally preferred over abrupt cessation
• For pellet users, simply not inserting new pellets allows levels to decline as the existing pellet dissolves, providing a natural taper
• For topical creams and troches, gradual dose reduction can be prescribed by your provider

Symptom recurrence:

• An estimated 50% of women experience some return of vasomotor symptoms after stopping HRT
• Recurrence rates are similar regardless of whether the original therapy was compounded or FDA-approved
• Severity of recurrence is typically similar to pre-treatment levels (not worse)

Transition options:

• Low-dose vaginal estrogen can continue even after stopping systemic HRT for persistent GSM symptoms
• Non-hormonal alternatives can be added if vasomotor symptoms recur
• If symptoms are well-controlled on compounded HRT but you wish to switch to FDA-approved products, your provider can identify equivalent FDA-approved options for estrogen and progesterone (compounded testosterone may need to continue if indicated)

Special Populations & Situations

Breast Cancer Survivors

Compounded bioidentical HRT is sometimes marketed to breast cancer survivors as a "safer" alternative to conventional HRT. This claim is not supported by evidence. Systemic HRT, whether compounded or FDA-approved, is generally contraindicated in breast cancer survivors. Low-dose vaginal estrogen may be considered for severe GSM symptoms under specialist guidance.

Premature Ovarian Insufficiency (POI)

Women with POI need hormone replacement until at least the average age of menopause. FDA-approved bioidentical estradiol and progesterone are the standard of care. There is no evidence that compounded formulations offer advantages for this population.

Women Who Need Testosterone

This is the clearest legitimate use case for compounding in the HRT space. No FDA-approved testosterone product exists for women. Compounded testosterone cream or gel, dosed to maintain levels in the physiologic premenopausal range (20-80 ng/dL), is the primary access route. ACOG recommends shared decision-making and advises against pellet therapy for testosterone delivery.

Women with Allergies to FDA-Approved Product Ingredients

If a patient has a documented allergy to a specific excipient in an FDA-approved product (e.g., peanut oil in Prometrium), compounding provides a way to access the same active hormone in a different vehicle. This is a traditional, medically appropriate use of compounding.

Patients Currently on Compounded HRT Who Want to Transition

Many women begin with compounded HRT and later wish to transition to FDA-approved products. A provider can typically identify FDA-approved equivalents for the estrogen and progesterone components. Compounded testosterone may need to continue. The transition can be done gradually with monitoring.

Regulatory, Insurance & International

United States (FDA)

FDA-approved bioidentical products: Numerous options exist across estrogen (oral, transdermal, vaginal), progesterone (oral, vaginal), and DHEA (vaginal). The FDA has approved the first combination bioidentical product, Bijuva (estradiol + progesterone capsules).

Compounding regulation: Section 503A pharmacies operate under state pharmacy board oversight and are exempt from federal FDA approval, cGMP, and labeling requirements. Section 503B outsourcing facilities are subject to FDA registration, cGMP, and inspection. The NASEM report (2020) recommended restricting compounded HRT use to situations where FDA-approved alternatives are not suitable.

2025 FDA label changes: The FDA modified warning labels on certain estrogen products in November 2025, including removal of the black box warning on low-dose vaginal estrogen. These label changes apply only to FDA-approved products. Compounded products were explicitly excluded.

Insurance: FDA-approved bioidentical HRT is typically covered by insurance (commercial and Medicare Part D). Compounded products are frequently not covered, resulting in higher out-of-pocket costs for patients.

United Kingdom (MHRA)

In the UK, the term "body identical" is preferred over "bioidentical" to describe hormones structurally identical to human hormones. Body-identical estradiol and micronized progesterone are available on the NHS. Compounded HRT is available from private providers but is not recommended by NICE, BMS, or the RCOG.

Canada (Health Canada)

FDA-approved equivalents are available in Canada as Health Canada-approved products. Compounding is regulated at the provincial level. Major medical organizations in Canada echo the positions of ACOG and NAMS.

Australia (TGA)

Bioidentical estradiol and progesterone are available as TGA-approved products. Compounded HRT is available from compounding pharmacies. The Australasian Menopause Society advises using registered products when available.

Cost Considerations

Compounded HRT is often marketed as more affordable, but the reality is mixed. FDA-approved generic estradiol (patches, tablets) and generic micronized progesterone are relatively inexpensive with insurance coverage. Compounded products are typically not covered by insurance. Pellet therapy, in particular, can be expensive ($300-600+ per insertion every 3-6 months, paid out of pocket).

Frequently Asked Questions

Q: Are bioidentical hormones and compounded hormones the same thing?
A: No. "Bioidentical" means the hormone is chemically identical to what your body produces. Many FDA-approved products are bioidentical (estradiol patches, micronized progesterone). "Compounded" means custom-mixed by a compounding pharmacy. Not all bioidentical hormones are compounded, and not all compounded hormones are bioidentical.

Q: Are compounded bioidentical hormones safer than FDA-approved hormones?
A: There is no scientific evidence supporting this claim. NAMS, ACOG, the Endocrine Society, and the FDA all state that compounded bioidentical hormones are not safer or more effective than FDA-approved alternatives. In fact, the lack of quality control with compounded products introduces additional risks.

Q: My provider recommended salivary hormone testing. Is this reliable?
A: ACOG, NAMS, and the Endocrine Society do not recommend salivary hormone testing for prescribing or monitoring HRT. Hormone levels in saliva do not reliably reflect blood levels or correlate with menopause symptoms. Dosing should be guided primarily by symptom response.

Q: Is there ever a good reason to use compounded HRT?
A: Yes. Legitimate reasons include: allergy to an ingredient in FDA-approved products, need for a specific dose not commercially available, and testosterone therapy for women (no FDA-approved product exists). Your provider should be able to articulate a specific medical reason for choosing compounded over FDA-approved.

Q: What about estriol? Is it a safer form of estrogen?
A: The FDA states it does not have evidence that estriol is safe and effective, or that it is a "safer form of estrogen." There are no FDA-approved products containing estriol. While estriol has weaker estrogen receptor binding than estradiol, no well-designed clinical studies have demonstrated it provides a safer therapeutic profile.

Q: Are pellets a good option for HRT?
A: ACOG recommends preparations other than pellet therapy for testosterone delivery based on the lack of safety data and the inability to remove the pellet once inserted. Pellets can provide sustained release, but the inability to adjust or discontinue quickly is a significant safety limitation.

Q: Why does my compounded HRT seem to work differently from batch to batch?
A: This may reflect the documented variability in compounded preparations. Studies have found that compounded products can deviate from their labeled dose by significant amounts. If you notice changes in symptom control, discuss this with your provider and consider requesting that the pharmacy verify the potency of recent batches.

Q: Can I switch from compounded to FDA-approved HRT?
A: In most cases, yes. Your provider can identify FDA-approved equivalents for the estrogen and progesterone components of your regimen. The exception is testosterone, where compounding may still be needed due to the lack of an FDA-approved product for women.

Q: Do compounding pharmacies have to report side effects to the FDA?
A: Pharmacies operating under Section 503A of the Federal Food, Drug, and Cosmetic Act are not required to report adverse events to the FDA. This means safety problems with compounded products may not be systematically tracked.

Q: Is compounded progesterone cream effective for menopause symptoms?
A: A systematic review of 3 RCTs found that available evidence does not support the use of bioidentical progesterone cream for managing vasomotor symptoms. Progesterone has poor transdermal bioavailability, and topical cream may not provide adequate endometrial protection for women with a uterus.

Q: My friend swears by compounded HRT. Should I try it?
A: Individual experiences are real and valid, but they cannot tell you what will work for you or whether a product is safe. The active hormones in compounded products (estradiol, progesterone, testosterone) are the same as in FDA-approved products. The positive experience your friend reports is likely due to the hormones themselves, not the compounding. Talk to your healthcare provider about which formulation is right for your specific situation.

Myth vs. Fact

Myth: "Bioidentical" means compounded.
Fact: Many FDA-approved products are bioidentical. Estradiol patches (Climara, Vivelle-Dot), estradiol gels (EstroGel, Divigel), and micronized progesterone (Prometrium) are all bioidentical, meaning they are chemically identical to the hormones your body produces. "Bioidentical" is a description of the molecule, not the manufacturing process [1][11].

Myth: Compounded bioidentical hormones are safer than FDA-approved HRT.
Fact: Every major medical organization that evaluates menopause treatments (NAMS, ACOG, Endocrine Society, FDA) has concluded that there is no evidence compounded bioidentical hormones are safer or more effective than FDA-approved alternatives. If the active hormone, dose, and route are the same, the risks and benefits are expected to be the same. Compounded products carry additional risks from lack of quality control [1][4][11].

Myth: Compounded HRT is "natural" while FDA-approved HRT is "synthetic."
Fact: Both compounded and FDA-approved bioidentical hormones are derived from plant sources (typically soy or wild yam) and undergo laboratory processing to produce the final hormone molecule. The end product is the same molecule regardless of manufacturing origin. The only truly synthetic HRT products are conjugated equine estrogens (Premarin, derived from horse urine) and certain progestins like medroxyprogesterone acetate (MPA), which are structurally different from human hormones [1][11].

Myth: Salivary hormone testing is essential for proper HRT dosing.
Fact: ACOG, NAMS, and the Endocrine Society do not recommend salivary hormone testing for prescribing or monitoring HRT. Hormone levels in saliva are extremely low and difficult to measure accurately, and they do not reliably reflect blood or tissue levels. Dosing should be guided by symptom response, not lab numbers [11].

Myth: Estriol is a "safer" form of estrogen that protects against breast cancer.
Fact: The FDA does not have evidence that estriol is safe and effective. No FDA-approved products containing estriol exist. While estriol has weaker receptor binding than estradiol, no well-designed clinical studies have demonstrated that estriol-containing combinations are safer than estradiol alone [4][6].

Myth: Compounded HRT is more personalized than FDA-approved HRT.
Fact: While compounding allows for custom doses and combinations, FDA-approved products come in a wide range of doses and delivery forms that allow substantial personalization. Estradiol patches alone come in five dose strengths. The Endocrine Society notes that hormone customization is very difficult to achieve because blood hormone levels are difficult to regulate accurately, regardless of whether the product is compounded or FDA-approved [1].

Myth: Once you start compounded HRT, you should only stop under the guidance of the compounding practitioner.
Fact: Any qualified healthcare provider can help you manage your HRT, including adjustments and discontinuation. You are not locked into a single provider or pharmacy. If you wish to transition from compounded to FDA-approved products, your provider can identify equivalent formulations.

Myth: "Custom-compounded" means each batch is made specifically for you.
Fact: While compounding pharmacies fill individual prescriptions, the compounding process still involves mixing from bulk ingredients. The customization refers to the specific dose and combination ordered by the prescriber. The quality of the final product depends entirely on the individual pharmacy's practices, which vary substantially and are not independently verified by the FDA [4][10].

Sources & References

Clinical Guidelines

[1] Santoro N, Braunstein GD, Butts CL, et al. Compounded bioidentical hormones in endocrinology practice: an Endocrine Society Scientific Statement. J Clin Endocrinol Metab. 2016;101(4):1318-1343. doi:10.1210/jc.2016-1271

[2] U.S. Food and Drug Administration. Human Drug Compounding. https://www.fda.gov/drugs/guidance-compliance-regulatory-information/human-drug-compounding

[3] U.S. Food and Drug Administration. Section 503A of the Federal Food, Drug, and Cosmetic Act. https://www.fda.gov/drugs/human-drug-compounding/section-503a-federal-food-drug-and-cosmetic-act

[4] National Academies of Sciences, Engineering, and Medicine. The Clinical Utility of Compounded Bioidentical Hormone Therapy: A Review of Safety, Effectiveness, and Use. Washington, DC: The National Academies Press; 2020. doi:10.17226/25791

[5] Pinkerton JV, Santoro N. Compounded bioidentical hormone therapy: identifying use trends and knowledge gaps among US women. Menopause. 2015;22(8):926-936. doi:10.1097/GME.0000000000000420

Regulatory and Government Sources

[6] U.S. Food and Drug Administration. Menopause & Hormones: Common Questions. https://www.fda.gov/media/130242/download

[7] Kuhl H. Pharmacology of estrogens and progestogens: influence of different routes of administration. Climacteric. 2005;8(suppl 1):3-63. doi:10.1080/13697130500148875

[8] Stanczyk FZ, Hapgood JP, Winer S, et al. Progestogens used in postmenopausal hormone therapy: differences in their pharmacological properties, intracellular actions, and clinical effects. Endocr Rev. 2013;34(2):171-208. doi:10.1210/er.2012-1008

Research Studies

[9] Stanczyk FZ, Matharu H, Winer SA. Bioidentical hormones. Climacteric. 2021;24(1):38-45. doi:10.1080/13697137.2020.1862079

[10] Stanczyk FZ, Niu C, Azen C, et al. Determination of estradiol and progesterone content in capsules and creams from compounding pharmacies. Menopause. 2019;26(8):966-971. doi:10.1097/GME.0000000000001356

[11] American College of Obstetricians and Gynecologists. Clinical Consensus No. 6: Compounded Bioidentical Menopausal Hormone Therapy. Obstet Gynecol. 2023;142(5):1266-1273. doi:10.1097/AOG.0000000000005395

[12] Donovitz GS. Low complication rates of testosterone and estradiol implants for androgen and estrogen replacement therapy in over 1 million procedures. Ther Adv Endocrinol Metab. 2021;12:20420188211015238. doi:10.1177/20420188211015238

[13] Liu Y, Yuan Y, Day AJ, et al. Safety and efficacy of compounded bioidentical hormone therapy (cBHT) in perimenopausal and postmenopausal women: a systematic review and meta-analysis of randomized controlled trials. Menopause. 2022;29(4):465-482. doi:10.1097/GME.0000000000001937

[14] Maclennan AH, Broadbent JL, Lester S, et al. Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes. Cochrane Database Syst Rev. 2004;(4):CD002978. doi:10.1002/14651858.CD002978.pub2

Landmark Trials and Position Statements

[15] Davis SR, Baber R, Panay N, et al. Global consensus position statement on the use of testosterone therapy for women. J Clin Endocrinol Metab. 2019;104(10):4660-4666. doi:10.1210/jc.2019-01603

[16] Glaser RL, York AE, Dimitrakakis C. Incidence of invasive breast cancer in women treated with testosterone implants: a prospective 10-year cohort study. BMC Cancer. 2019;19:1271-1278. doi:10.1186/s12885-019-6457-8

[17] The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. doi:10.1097/GME.0000000000002028

[18] Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333. doi:10.1001/jama.288.3.321

Related Guides & Cross-Links

Same Category (Treatment Overviews)

• Non-Hormonal Menopause Treatments
• Getting Started with HRT
• Transdermal HRT (Patches, Gels, Sprays)
• Vaginal Estrogen Therapy
• Testosterone Therapy for Women

Related Medications (FDA-Approved Bioidentical)

• 17B-Estradiol (Bioidentical)
• Micronized Progesterone (Prometrium)
• DHEA/Prasterone (Intrarosa)
• Estradiol + Progesterone (Bijuva)

Related Compounded Formulations

• Biest (E2 + E3)
• Triest (E1 + E2 + E3)

Educational Guides

• HRT Myths vs Facts
• The WHI Study Explained

Complementary Supplement Guides

• Vitamin D
• Calcium
• Magnesium
• Omega-3 Fatty Acids
• Black Cohosh