4 Things to Know About Bioidentical or Body-Identical HRT

Body identical hormone therapy.

Looking for clarity around bioidentical hormone replacement (HRT)?

Modern hormone therapy is very different from old medications such as Premarin and Provera.

Here’s everything you need to know.

You’ll need progesterone before you need estrogen

Perimenopause or “second puberty” can start years before your periods actually stop. The earliest symptoms of perimenopause include heavy periods, insomnia, and anxiety, and are actually the result of losing progesterone, not estrogen.

Progesterone drops during perimenopause because you start having more anovulatory cycles or cycles with unopposed estrogen.

👉 Tip: An anovulatory cycle is a cycle in which ovulation did not occur and progesterone was not made.

Progesterone drops during perimenopause but you can have up to three times more estrogen than you did before.

progesterone at perimenopause
Low progesterone and high fluctuating estrogen during perimenopause.

High, fluctuating estrogen contributes to the symptoms of anxiety, migraines, and histamine or mast cell activation. (Symptoms that are sometimes referred to as “estrogen dominance” — a term I don’t use.)

Taking estrogen during perimenopause is not advisable. Progesterone is a better option.

Progesterone can relieve symptoms and lighten periods

Micronized or bioidentical progesterone can relieve the mood and sleep symptoms of perimenopause including anxiety, insomnia, hot flushes, and reduced ability to cope with stress. Progesterone calms the brain and nervous system by converting to the neurosteroid allopregnanolone (ALLO) which acts on GABA receptors.

The advantage of taking progesterone on its own (without estrogen) is that it’s safer in terms of breast cancer risk and can be stopped anytime without triggering hot flushes. (Stopping estrogen suddenly can trigger hot flushes, so estrogen needs to be weaned down.)

Micronized progesterone capsules are prescription-only and are available as a compounded capsule or the brand names Prometrium, Utrogestan, or Teva generic capsules. They’re highly sedating so should be taken at bedtime.

Progesterone can also make periods lighter and is a good alternative to progestin drugs such as the pill and the hormonal IUD. Read For Healthcare Providers: Managing Menorrhagia Without Surgery.

The big difference between progesterone and progestins is that progesterone is usually good for mood, hair, bones, and heart, and may help to prevent breast cancer. Progestins, on the other hand, are usually bad for mood and can cause hair loss and increase the risk of breast cancer. Read The crucial difference between progesterone and progestins.

👉 Tip: Progesterone stimulates metabolic rate so can help to prevent menopausal weight gain.

For more information about the benefits of progesterone, read the Progesterone Therapy section of Prof Jerilynn Prior’s CeMCOR site. Prof Prior has also published several papers about the benefits of using progesterone-alone for the hot flushes of menopause and perimenopause.

You may eventually need estrogen

The later symptoms of perimenopause (hot flushes, vaginal dryness, weight gain, and depression) are the result of losing estrogen. They typically coincide with the final disappearance of periods.

At this stage, some estrogen can be helpful for symptom relief, but only in combination with progesterone!

My advice is to start with progesterone and if that doesn’t relieve all the symptoms, then look to a low-dose transdermal body-identical estradiol product such as Vagifem, Estradot, or Sandrena.

👉 Tip: You always need progesterone, even if you don’t have a uterus. Why? Because natural progesterone is good for mood and may help to protects breasts.

Transdermal body-identical estradiol is safer than oral estrogen but the safety of estrogen, in general, is still up for debate. Many experts including Dr Avrum Bluming, the author of Estrogen Matters, argue that estrogen is a lot safer than we’ve been led to believe.

I think there is a case for taking estrogen, but only in close consultation with your doctor. Here are a few more things to keep in mind:

Bioidentical or body-identical is the safest kind of hormone therapy

Estradiol and progesterone are better and safer when they are “identical to the body’s own hormones.” Such hormones can be called body-identical or bioidentical because the two terms mean the same thing.

Body-identical is the preferred term for all the modern estradiol and progesterone formulations that are “identical to the body’s own hormones.” They include the brands mentioned in this blog post.

Bioidentical is the term for compounded hormones used during all the decades when compounding was the only way to access estradiol and progesterone “identical to the body’s own hormones.”

Your doctor prefers the term body-identical because she prefers approved medications and not formulas made by a compounding chemist. She has concerns about the quality of compounded formulations and does not agree that hormone formulas can be “individualized” based on blood, saliva, or urine tests.

I agree with the last point. There is no way to “tailor” hormones based on any kind of testing.

Just to say again: the best and safest strategy is to start with progesterone on its own, and then, if that doesn’t relieve symptoms, consider adding low-dose transdermal estradiol such as Vagifem or Estradot 25.

Hopefully, that has clarified a few things. You may still be wondering if you need hormones at all or if you could get by with just lifestyle and supplements?

The short answer is yes. Lifestyle and supplements (especially magnesium) can be very helpful. Read Rescue prescription for perimenopause. Other helpful strategies include:

  • reducing histamine foods
  • quitting alcohol
  • exercising regularly.

If, after doing all that, you still have symptoms, it’s reasonable to take body-identical hormones, at least for a few years. They’re a better and safer treatment than the pill or antidepressants.

Ask me in the comments.

131 thoughts on “4 Things to Know About Bioidentical or Body-Identical HRT”

  1. I’ll try that combination. Is it possible that I need a higher dose of Estrogen (I was given the lowest dose) or that it takes a few more months before it improves? Or perhaps it’s not BV after all. The pH is always normal and lab test showed normal flora repeatedly, but my Gyn insists that it is BV.

  2. I am trying to reduce it because it didn’t seem to work, although it may have helped a little. I still had a lot of burning and discharge, but little less of the other irritations. I worry about taking estrogen for life. I would prefer getting rid of the BV first. But Flagyl and boric acid didn’t help. I tried oral and vaginal probiotics and a candida diet without success.

    • The thing is that for menopausal women, a vaginal estrogen probably is the best way to get rid of BV. The best is probably a combination of estrogen and the vaginal probiotic I describe in my book with the strains Lactobacillus rhamnosus, GR-1 and Lactobacillus reuteri, RC-14.

  3. Look into these:
    Good Love Balance gel. Vinegar plus water recipe for vagina use helps give the right pH to encourage good microbes. Get unsweetened yogurt and smear it around. Coconut oil will kill a lot of microbes, only best if you have high yeast. Use a suppository with probiotics Good for female—you can insert it or open an smear it around. If you have histamine intolerance, learn how to manage it. @histaminehacker

  4. I have a lot of vaginal issues (burning, discharge, irritation as if something is in there). My GYN (menopause specialist) says I have BV and need vaginal estrogen for life to balance the microbes. The vaginal estrogen helped minimally after 3 m. But now that I tried to reduce the dose by half, it is getting worse. Is there another way to balance the vaginal microbes?

  5. Do a search on ChrisKresser.com for osteoporosis. You will likely find these suggestions for prevention: Lower or eliminate grains due to phytates which bind to minerals when they are in your gut with your food. Take bone broths or collagen. Optimize your calcium to magnesium ratio. Eat enough protein. Get fat soluble vitamins D3 and K2. I also take Pure Encapsulations Mineral 650 and I add 15 mg of zinc. Also, do weight bearing exercise plus walking or other exercise. Broccoli is one of the plants with highest BIOAVAILABLE calcium.

  6. My mother died of a heart attack. I’m not having many symptoms (I last had a period 4 months ago, and before that, it was pretty regular. I’m 50) but wonder if there would be a reason to do something like an estridiol patch for heart reasons and osteoporosis. (My mother also had that and my bones are tiny.)

  7. Hello, Lara
    I started taking magnesium pills but I got an allergic reaction :(, I got eczema on my face skin.
    what should I do about them?

  8. Hi! Your book was a big eye-opener for me. Can you recommend anyone in Sydney or Switzerland for (suspected) post-pill pcos? Thank you so much

  9. Hello, my mom is 69 years old and now days still suffering from hot flushes, not sleeping, joints pain, etc. I would like to know your opinion about her starting to take magnesium and progesteron ❤️
    We are waiting for your book translate in spanish.
    Thank you very much

  10. Yes. So I can’t continue to take progesterone. What alternatives would you suggest?
    Also can estrogen be taken safely without progesterone?

  11. Is there a herbal alternative to Prometrium? I’m now postmenopausal; my progesterone levels tested very low, but I can’t tolerate taking Prometrium due to the hideous fatigue and depression it is causing even at a half dose. I’m also taking a 1/4 troche (1mg oestradiol + 2mg oestriol) daily. Thank you.

  12. Most informative thank you. Re starting estrogen you say in the first year of menopause… is that one year after last period? To have an idea around timing. I ve started already on progesterone cream made from yams…it is helping for sure but maybe not enough?? My sleep is barely happening! Am taking Dormidiana…is this a histamine? Does help sleep for sure. Is this ok? Thanks. Like the article above.

  13. Hi Dr. Briden. My last period was in March and I started on continuous HRT in July. Estradiol patch plus 100mg of progesterone. My dose of estradiol has been increased to .05 and symptoms are improving. I just got a period today. I’m sure it’s a period because I felt it coming with all of the other bodily signs that I normally experience before my period starts. Is it ok to be on continuous HRT if I just had a period? Is this normal?

    • It’s not unusual to get the odd period during the year or two when periods are stopping, and most doctors say to continue HRT. Best to check with yours.

  14. Is there great risk to not taking hormones at age 48 after a total hysterectomy which occurred at age 43? I took compounded cream hormones for a couple of years, but then stopped.

  15. Dr. Lara,

    I took progesterone 200mg on the last two weeks of my cycle due to heavy periods and bloating. I saw a huge difference, I was retaining liquids, and with the progesterone I felt lighter and my heavy period was lighter too. The only is that when I stopped taking progesterone I got bad headaches, it’s been a week that I’m with headaches. I thought it was a tooth I was having problems, but I think it might be cesation of progesterone intake. Could that be possible ? Should I try 100mg instead of 200mg (I;m 40 years old)?

  16. Hi Dr. Briden. I’ve recently started on Prometrium 100 mg and Estradiol patch .0375. I see you recommended taking a few days break about once a month. Can you please elaborate on that? Does it matter when and if I’ve only been on these for a couple of months should I wait to take a break?

  17. Dr Briden,
    Thank you for your work and for writing your book. I have a few questions:
    Can a 66 year old balance her hormones if she has never done so in her life time? I was diagnosed with Hashimoto’s about 10 yrs ago. But just recently am experiencing many itchy hives on my upper arms and upper back. In addition see more dark spots on my face, and arms and am very tired. I am wondering if Synthroid and Cytomel thyroid medications are not enough and a small dose of iodine might correct my problem? I have just learned of estrogen excess from your book and also realized my histamine issue has escalated recently. I am allergic to aspirin and have a touch of asthma. Are these symptoms related to estrogen excess and histamine sensitivity? My weight is the highest its ever been and I am always depressed. Can you explain what you think I might be dealing with, without an official diagnosis? I understand the limitations through this comment format.
    Thank you,

  18. Hi Dr. Briden,
    despite the hormones they gave me a few months ago not being bio identical, would you consider them equally safe? You haven’t heard anything of using phytoestrogens like red clover, horny goat weed, kudzu, etc. to help with the maintenance of bones?
    I do eat well over 200g of carbohydrates and have no vitamin or mineral deficiencies according to my blood tests, yet my estrogen is still drastically low.
    I have not read the book, but I have heard it’s an excellent read.

    • Large doses of phytoestrogens do not help hypothalamic amenorrhea and in fact, have an anti-estrogen, ovulation-suppressing effect. (small doses from food are fine)

      Are you eating 2500 calories per day?

      And in answer to your question, the safest protocol for short-term hormone replacement for HA is body-identical hormones.

  19. Hi Lara, does that mean yes, still safe or you don’t really know as studies have not been done. thanks, would love some clarity on this.

  20. I was prescribed topical estrogen gel and a progesterone tab just 8 months ago when i discovered I had osteoporosis to preserve my bone density until I get my period back. I have been suffering with HA since 15, and I am 26 now. I broke my hip 10 months ago which is how we found out about the osteoporosis.
    My question is, is HRT safe? I’m still a bit confused after reading this. I stopped the HRT 4 months in, afraid, and am now taking red clover extract because I have found studies it helps with bone density in menopausal women, despite the fact I am not kn menopause.
    Do you have some insight?

    • The current protocol is to give body-identical hormone replacement (Estraderm patch plus Prometrium) during the recovery phase of HA or RED-s. And I think that’s a reasonable thing to do short-term.

      But, of course, the more critical part of the plan is to recover your cycles by increasing your food intake at least 2500 calories per day plus 200 grams carbohydrate. Have you read “No period, now what?” by Nicola Rinaldi? Once you’re cycling, you won’t need the hormones.

  21. Dear Doctor,

    I am seeking information about progesterone use for a post menopausal woman (I am 76). I have fatigue, abdominal weight gain, hair loss that’s getting worse, and sleep issues. My DUTCH test showed I have very high DHEA and testosterone.

    Like so many people with adrenal fatigue issues, mine stemmed from a period of severe stress that I hope will be getting better. I have been symptomatic for about three years now. Before that, I was in perfect health.

    What do you think about progesterone for a woman my age? What should I read to find out more about progesterone, DHEA, cortisol and testosterone for a woman my age? I don’t have any medical background but I am passionately interested in getting well and living a healthy life.

    Love your work and I am so happy to find you. Wish we lived on the same side of the world! Many thanks and please keep me on your mailing list.

    • Hi Emily.

      I think it’s unlikely that progesterone would be the right treatment for you at 76. Especially since you say you were well three years ago (at 73) and were obviously well past menopause then. I would instead consider looking at magnesium and B-vitamins and other ways to stabilise the HPA axis.

  22. Hi I’m a 53 old women and lately I’v been experiencing hot flashes and aches in my joints. It’s really bad with joints because I suffer from EDS and my joints are very unstable and aches a lot. But it’s so much worse now. I suffer from really bad headache when I get flushed. It’s terrible so I wonder if I start with progestrone now. Can I do even if my period not regular anymore? Can you start even if you don’t have first date of your menustration. And which products can I find on line??

  23. Dear Dr. Lara Briden,

    I am 44 years old and for the last 4 years have been telling my GYN’ that my hormones are off and now I am almost bald. My hair is thinning so badly, and no one can figure it out. My GYN says to wait on the Endo, the Endo wants me to be off Spiro and Progesterone pill before he will check my blood, I went to HTR and got the progesterone but gave up on it as its very expensive. I am at my witts end and don’t want to lose my hair. I came across your post/blog and I think you have me pegged. Here is what I take, 200mg Progesterone at night, multi vitamin, Spiro 100 MG for hair loss and Viviscal Pro. I have been treated by my primary, derm, endo, and I am at my limit of giving up and totally losing my self esteem. Please help. Would love to speak with you

  24. I am 60 & well & truly post menopause. My Dr did bloods to check hormone levels & both progesterone & estrogen are practically nonexistent. I have gained too much weight & skin so dry nothing helps. My moods fluctuating as well, feeling unusually down & sad. I work full-time in a high stress (sedentary) job. My diet is 95% veg but crave carbs/sugar at night. Should I take progesterone?

    • At 60, you’re probably quite some time after menopause. I would be more tempted to look at something like magnesium to help your body cope with stress. Read 8 ways magnesium rescues hormones.

      Also, you’re not vegetarian, are you? The zinc, vitamin B6, and taurine from animal protein can be important for mood.

  25. I take Estrodial transdermal gel. It’s not on your list of recommended brand names. It says it’s estrodial, the ingredient. Same thing?

  26. Morning Laura,
    I am 50, allegedly at peri stage.
    However at the time I was vit D deficient, vegan, (previously vege since aged 10) low weight thus I believe this can mimic menopausal traits?
    My sleep patterns are erratic, I am now taking magnesium 500mg.
    The lifestyle I lead is still vegan, exercise most nights, drink 3-4 lites of water daily.
    My doctor has prescribed estradot 50mg and crinone gel 8%.Prior to that I was taking evorel which produced the most low to high moods since being a teen!!!
    Is this the best way to go?

  27. I take 300 mg progesterone and 2MG0.5ML BIEst. Now at age 59 I have been on this for 10 years. My saliva test was high in progesterone. How long do I continue on these prescriptions?

  28. Hi Lara, I am 44 and have all the symptoms of low estrogen, apart from sore breasts from around ovulation to day one or two of my cycle. I find this confusing, as painful breasts are a sign of high estrogen correct? Would I benefit from a progesterone cream? and if so, when would be the best time to use it? thanks

  29. We just decided to go off both BIO EST/TEST for 8 weeks and tried compounded Pregnenolone 25 mg, and Compounded Progesterone (blue dye allergy). After two days, very overly emotional, worse insomnia and irritability? I am in dire need of resolving acute INSOMNIA and new hot flashes at night. My first try at BIO EST/TEST injections resolved all of these symptoms for 4 weeks but then was inconsistent. I’d love to figure this out. My practitioner is open to suggestions

    • If you stopped estrogen cold turkey, then you could just be having symptoms of estrogen withdrawal. In general, it’s better to wean down estrogen.

  30. Thank you for pointing me in the right direction! I’d like more info on histamine foods, too. Is it possible to correct the imbalance through diet alone?

    • Jane, I have histamine intolerance, and I have found that as I have gotten my histamine under control and possibly my gut is actually healing, I have had much calmer PMS which I used to think was PMDD, because mainly I only ever got dysphoria, brain fod and memory problems plus fatigue. So, definitely mood and cognitive symptoms. So, I’d love to share resources for histamine reduction. You are welcome to email me and I would tell you what I have done (except I’ll have to shorten it from the real story,but I still have many good ideas to share and you can just choose what sounds right to you). I’m NOT a practitioner, I’m just a patient with some success. Rachel @ Rachel Ernst dot com

  31. Hi Laura, in light of the recent warnings about HRT do you still stand firm in these protocols- i.e. prometrium being safe as a progesterone and estradot as estrogen or do they cause breast cancer so we should not use them . Thanks, so confused after all the press today. Josie

    • perfect timing with your question. I’m just reading the full article now.
      They do not provide any stats at all for Prometrium-only treatment or for specifically the combination of Prometrium plus low-dose transdermal estradiol.

  32. Thank you for your work! I recently purchased your book and am looking forward to reading. I have one question I’m hoping you can answer.

    Background: I am 48 years old with a diagnosis of AUB, no hyperplasia (normal uterine biopsy and ultrasound–except for small fibroid–within the last 6 months). For the past 6 – 12 months, I have begun having period flooding, long periods, and erratic cycles (anywhere from 3 weeks to 9 weeks apart). My doctor prescribed Medroxyprogesterone a few months back, but I have not yet taken it due to concerns about serious and unpleasant side effects. I have a followup appointment this week and plan to discuss with her the possibility of taking Prometrium or other body-identical progesterone instead.

    My question: I still have a concern about side effects of body-identical progesterone. Websites including iodine.com, medscape, and WebMD list many of the same serious side effects & risks for Prometrium as for Provera, including blood clots, stroke, breast cancer, and liver disease. Can you please comment. Thank you!

    • Despite growing evidence that progesterone is much safer than progestins, almost all sources list the side effects of progestins as the side effects of progesterone.

      I hope this will change one day in the near future but it’s a relic of the old paradigm that progestins are the same as progesterone.

  33. Thank you for your work! I have bought your book and looking forward to reading. I’m hoping you can help me with one question.

    Background: I’m 48 and have been having flooding and erratic cycles for around 6 – 12 months. Endometrial biopsy & ultrasound both normal within the last 6 months; diagnosis = AUB without hyperplasia. My doctor prescribed Medroxyprogesterone, but I have elected not to take it due to concern about the many serious & unpleasant side effects. I have another follow up appointment with her this week and plan to discuss your recommendation of body identical progesterone.

    My question: There seems to be a lot of contradictory information about possible side effects of Prometrium. Sites including Medscape, iodine.com, and WebMD list for Prometrium many of the same side effects as for Provera, including blood clots, breast cancer, and liver disease. Can you please comment.

  34. Hi Dr. Briden~

    Your Period Repair Manual has been a bible for me and a much appreciated resource when I came off the pill at 35 and wasn’t getting my period back- thank you!

    Now nearing 40, I have kept diligent track of my BBT and charted my cycles in that time and have noticed an overall trend of what appears to be “luteal phase defect” – I typically don’t ovulate until day 20-25, and then my temperature rise only lasts 8-10 day before my period, with spotting before my periods. So overall a normal length cycle, but only 1/3 of it in luteal phase! (My periods are very light, and have been ever since they resumed post period.) Could body identical progesterone help me, and if so what days would you recommend taking it? Thanks so very much!

    • yes, the luteal phase can shorten during perimenopause, and yes, taking progesterone during the luteal phase can help with symptoms.

  35. one of my peri symptons is joint pain, not sure what causes that? as I am still having my period
    this summer I noticed my 25-27 day cycle has been lengthened to 30days , this month 35days, joint pain are getting worse. use to have very heavy period, so been put on progesterone, and it lightened my period somewhat, but still heavy, I start to take curcumin supplement, and I noticed
    my period is less now, I remember you mention about how turmeric can lighten up periods, but like to know the underlying mechanism, can you explain that to me thanks

  36. Can you comment if one has been on all 3 bio hormones and wanted to try progesterone again, would it be safe to discontinue bio estrogen/testosterone without having menopause symptoms? I’d like to ask a practitioner about trying progesterone alone due to MCS/histamine problems mainly. I would not enjoy the return of hot flashes etc however….thank you Dr Briden. Loving this thread!

    • Testosterone can usually be stopped any time with no problem.
      Estrogen is addictive, so it may need to be weaned down. In other words, stopping estrogen suddenly could cause hot flashes.
      Normally, progesterone on its own can help to some degree with hot flashes. But may not be able to compensate completely for a sudden drop in estrogen.
      But check with your doctor, of course.

  37. In my 40’s I was oestrogen dominant with fibroids, heavy periods, flooding etc. Now 53, still having periods although in the last couple of months have been less regular (used to be 28days). Obviously peri-menopausal now but symptoms such as hot flushes, sleep disruptions are minor but still around as I have overhauled diet and supplements. Interestingly I am getting sore swollen breasts, which I haven’t had for some years. Having read your blog and website, I am wondering if I would benefit from taking progesterone. What are your thoughts?

  38. I was just recently diagnosed having simple hyperplasia not atopic. I’m 43 and my doctor wants me to use the Mirena IUD and or a progestin pill only for this. I asked her about using a body identical progesterone instead and she there is no such thing. Would a body identical/micronized progesterone help in this situation?

    • Body-identical progesterone (Prometrium or Utrogestan capsules) can be an option for some types of hyperplasia, but not all. Best to check with your doctor again but don’t use the word “bioidentical.” Instead, just say Prometrium if you’re in the States or Utrogestan in the UK.

  39. Hi Lara

    I’ve been taking magnesium, taurine & B6 as your book suggests, and am now thinking about progesterone.

    Do you find taking it cyclically can help with symptoms all month, or mainly just on the days it’s taken? My most intense symptoms are in the first half of my cycle (anxiety, low mood, brain fog). I do have some of these premenstrually too, and guess more progesterone could help then. But could it also help pre-ovulation, if I wasn’t taking it on those days? Or if not, is it an option to take it continuously?

    For background: I’m 48, having very light periods anything from 18-35 days apart. Apparently still ovulating more often than not (I take my temperature). I often feel hot, but not full-on flashes like many people describe.

    Thanks for any thoughts you have!

    • The half-life of progesterone is 3 to 90 minutes, so it is eliminated fairly quickly. And no, we don’t store it.
      We make it every day for the luteal phase and then none until the next ovulation.

  40. I’m 39 and have had only one working ovary since I was a teenager. In my early 30s I was diagnosed with PMDD and used symptom tracking to pinpoint my triggers- dropping estrogen after ovulation sends me into tailspins. Usually my moods pick up right as my period starts and estrogen starts to rise again, but I think my estrogen isn’t picking up quite like it used to. I’m having longer and heavier periods, hot flashes, headaches, and am still depressed at the beginning of my cycles- whereas I used to be super happy at that time (yes, I had good moods during my period!) With my PMDD, is progesterone really the best choice for me in perimenopause? Or am I going to need estrogen soon, too? Thank you for your help!

  41. Hello Lara and thank you for your blog. Is it safe to try progesterone therapy for improving stress tolerance and sleep while still having ovulatory cycles and producing good amounts of progesterone (according to blood test and a naturopathic doctor)? Thank you very much!

  42. Hi Dr Briden,

    Could you please write about sensitivity to progesterone?
    I was recently prescribed 100mg of body-identical progesterone capsules to treat anovulatory cycles.
    So far I’ve taken it for my past three cycles, and each time it has given me insomnia, anxiety, & leaves me feeling groggy, dizzy & low energy. I just don’t feel like myself when I’m on it.

    Thank you.

  43. I took 100mg for migranes during the luteal phase and it helped but didn´t stop them. I started taking 200mg and the ovulation & pre period migranes stopped. Why not try upping it to 200mg and see what happens?

  44. Thank you for this.
    The generic HRT approach is quite significant I think – as we all had/have different amounts of hormones anyway before any fluctuations or change. Do you agree?
    Still so if i understand you, staying on a progesterone + oestrogen HRT would be reasonable bet? I have been on this for 4 years since starting to be perimenopausal 4 years ago. I have refused the mirena coil plus oestrogen only as i do not want a coil inside me.
    Thirdly .. I wanted some testosterone as part of my repleacemnts as we also lose that but nothing is available apart from a gel, no controlled amount and possible side effects of permanent voice change… what are your thoughts on the inclusion

    • It’s true that our hormones fluctuate when we’re still cyclic and making our own hormones. But there is no logical way to mimic that. And I’m not even sure that would the right approach.

      At this stage, my best understanding is what I’ve described in this blog post. 1) that we start by taking progesterone-alone because progesterone is beneficial and is safer than estrogen, and 2) take a small amount of transdermal estradiol if needed for symptoms. Start low and only go up if needed.

      As for testosterone, I’m very leery of it, given the new research that menopause is already a state of relative “testosterone dominance” and that testosterone can promote insulin resistance in women.

  45. I had Mirena implant a few years ago due to menorrhagia and endometrial hyperplasia. Bled non-stop, terrible mood swings and acne from it, so out it came. Fast forward and I am now experiencing much heavier bleeding, irregular cycles, hot flashes, waking for the day at 2am, weight gain, low mood. I am 41 with endometriosis that has left me with part of one ovary. Just asked dr to prescribe me prometrium and instead they will only prescribe progestin in oral, shot, or implant form, which obviously did not go well before. What can I do to get some relief for what seems to be perimenopause/estrogen dominance? And why only progestin rx from dr?

  46. It was day 21 or 22. The ideal time for the test to be taken. I don’t have any other symptoms for low estrogen other than low libido, weight gain (quit a bit (10 lbs) and fast in the last 3-4 months, with no diet or exercise change), feeling a little blue at times, but that is it. No hot flashes or vaginal dryness. But I do spot pink before most periods for about a week in the mornings only. Like it looks like I’m getting my period but I’m not.

  47. Also… thank you for your work! It has helped me feel a sense of direction. I guess I’d just like to know if you think that I should be looking into hormonal replacement therapy based on my age and current symptoms.

  48. I am 37 and I read your book. I was told that my last two miscarriages were because of chromosomal abnormalities and after testing learned that I likely do not have many viable eggs left and the doctor labeled me as “perimenopausal” I tried to see a midlife specialist at the advisement of the fertility doctor to learn about how to keep an eye on my hormones and see if I need hormonal replacement therapy to help prevent osteoporosis or heart problems that could occur from my hormones being “off” at an early age. The midlife doctor insisted that I don’t need to see her until a year after I stopped having my period. My periods are still regular but went from 28 day cycle to 23 day cycle and are fairly light. Who should I be seeing to manage my care? I have no idea where to begin. Should I just ask my PCP to help with this?

  49. Just wanted to say thank you for all the research and information you have provided over the years. You have helped me conquer the pain of endometriosis and subsequent flooding. Progesterone is a good send and so are you! Keep up the incredible work. You are making a HUGE difference in people’s lives, especially mine. 🙂

  50. Hi, Dr. Briden

    can you tell me if zinc increase level of testosterone in your body? and is there any other way to minimize the up and downs of hormone during perimenopause? I am taking
    100mg Prometrium, helped somewhat, but still got lots of peri symptom,
    my ND thinks it caused by the fluctuating level of estrogen,my MD suggested BC pills, which I turned it down. my estrogen level are on the low side from the test i did. but my ND said there must be a surge of my estrogen at some point of my cycle, as my period is on the heavy side.


    • See Chapter 10 of Period Repair Manual for an entire section about “the estrogen rollercoaster” of perimenopause.

  51. I´ve finally managed to obtain Utrogestan for cyclical migranes and I take 100mg in the morning and 100mg before bed for 14 to 15 days. I´ve had no migraines what so ever so I am thrilled, thank you for this information.

    HOWEVER I have started to suffer from severe acid reflux during these days and I have read that hormone changes can cause the lower esophageal sphincter to relax causing acid reflux.

    Has anyone else suffered reflux once they started taking Utrogestan?

    I wonder whether taking them vaginally would help?

    I´m thrilled I´ve lost the headaches but this heartburn and reflux is also a pain.

    • I suspect it’s the morning dose giving you problems.
      Your doctor might be open to you switching to only a bedtime dose (100 or 200 mg) but talk to her, of course.

  52. I have been given compounded bioidentical forms and just progesterone with doses between 25 mg to 400 mg (gall bladder removed at this dose doctor felt progesterone caused this) also have many mast cell issues. Would love to figure this out after many functional MD’s have tried many different regimes. Complete hysterectomy early 40’a due to bursting cysts on ovaries and repeated hospitalization with kidney infections. Also periodic kidney stones. Have Sxs of estrogen dominance and low estrogen

    • With my patients in a similar situation, I start by treating the mast cell issues (with, for example, dairy-free diet, vitamin B6, quercetin). And maybe give iodine to stabilise hormone receptors.

      Then start with low-dose oral progesterone — and no other hormones.

      But check with your doctor, of course.

  53. Hi Lara, I am going to start prometrium soon. 200 mg My hormones were tested. I have estrogen that is off the charts. Progesterone is at high end of normal. Horrible insomnia, bleeding, acne, receding gums, and headaches. How long should I go between hormone re-tests? How long should I be on it in general?

    Also wondering about cancer risk with body identical estrogen for women when it is needed.

    How long should a woman generally be on all of this? How many years after menopause?

  54. What is your opinion about using bio identical hormone therapy in early 30s to regulate cycles when a person has pcos with extremely long cycles read more than 3 months without periods?

  55. Compounded, body identical bioidentical forms (I have tried many!) have the opposite effect on me. They cause puffiness, irritability, insomnia, weight gain – I’d love to hear what a person does as my practitioners have no answers. pregnenlone it’s precursor does the same.

  56. Thank you!! I take zinc. I’m 46 and not ovulating a whole lot. No bc pills. I didn’t know about insulin resistance. That’s certainly not worth it. I’m thin, but my fasting glucose is high. Thank you.

    • So much would depend on context — the age of the patient; if she’s still ovulating; what other symptoms are present; if she’s on the pill (all hormonal birth control suppresses androgens).

      In general, I am not a fan of testosterone or DHEA supplements for women because they might cause or worsen insulin resistance. But there could be some circumstances where it’s appropriate.

      General nutritional support such as zinc can support DHEA production from the adrenal glands.

  57. Hi Lara, great post as always!
    What is your thoughts on normal progesterone (meaning ovulation occurred) but very low estrogen in the early 40s. Shown from a Dutch test that it’s post menopausal levels of estrogen. Testosterone perfect as well as DHEA.
    Thank you for any insight!

    • Really, by definition, if you can reach ovulation, then you have enough estrogen.
      On which day of your cycle (relative to ovulation) was that “low estrogen” reading sampled?

  58. What do you do for low testosterone that’s not DHEA? Low libido has been an issue for years, tested very low testosterone. Sorry, not original poster, just curious.

  59. Hi Dr. Lara, I purchased your book and found it to be helpful, even purchased 1 for my neighbor. I am 54 with PCOS had horrible heavy periods only my last 2 years, other than that ! had periods every few months sometimes going for 1 yr without, I had ablasion done about 3 years ago so no periods anymore, I now have night sweats, hot flashes, irritability, mood swings, anxiety and weight gain around the tummy, also exhausted constantly, when I get up and all day long, nothing helps. I have always been chubby due to the PCOS now it is going more towards the tummy, I feel awful like I don’t want to get up in the morning, too tired.
    My gyno isn’t much help, she is always pushing something to purchase, she sells a lot of products, supplements, etc. She had me taking prometrium which was giving me nightmares now I am taking biodentical progesterone pills, 200mg and she just gave me an estrogen patch, I didn’t start it yet because 1 of the side effects mentioned weight gain, I cant have that. She told me to purchase ashwaganda, and an adrenal fatigue product from her. So far nothing has made a difference. My primary care doctor gave me metaformin to take for PCOS, I took that years ago and cant decide if I want to start again, of course I was also given birth control pills for PCOS and took them for years.

    I am miserable and the doctors around my area could care less about PCOS, I think it is not an expensive disease, and there is no cure for it so they don’t bother with it.

    Any help, suggestions would be so appreciated,

  60. I am 62 and have been on bio identical hormone‘s since age 58. I had been in post menopause since age 52 . I started the Wiley protocol which consist of bio identical estradiol, progesterone and testosterone. You mentioned the risk for heart disease. This concerns me greatly because of my age I will also mention that I have periods again. Every month like clockwork. My naturopathic doctor has 80-year-olds on the Wiley protocol. This is the same bio identical hormone‘s Recommended by Suzanne Somers. Can you give me some advice on this? What are the cardiovascular risks and why is there a greater risk for this. Younger women seldom have cardiovascular disease and yet hormones are raging in their bodies. Are there any other risks of bio identical hormone usage in older women ?

    • Thanks for commenting. This is an important part of the discussion.

      I do not recommend the so-called Wiley protocol of high dose hormone cycling because really do not like the idea of using such high doses of hormones that women keep bleeding! (They’re withdrawal bleeds– not true cycles.)

      With regard estrogen and cardiovascular disease, the current understanding is that estrogen capsules can carry a clot risk BUT that estrogen generally helps to protect against cardiovascular disease. It’s all about the dose and the timing.

      Finally, I have concerns about testosterone for women. There’s some evidence that it can promote insulin resistance and abdominal weight gain.

  61. Curious why so many doctors still refer to Progesterone as the “PMS hormone,” and use that as a reason why they typically don’t prescribe body-identical progesterone on its own?

  62. I am a huge fan of your work, Dr. Briden. I recommend your book all the time to friends. I am 44 and started 100mg of progesterone during my luteal phase for PMS and insomnia. It has helped so much! But my functional medicine doctor suggested I increase my dose to 200mg/400mg to help manage my menstrual migraines. Are there any risks to increasing it so much? Thanks!

  63. I’m 44. I did 3 months of lupron injections last year and this January had a hysterectomy..including the removal of both ovaries. The reason for this was adenomyosis and the mast cell disorder I have. I was having severe allergic reactions before and during my periods. The assumption is that I’m allergic to my own estrogen…maybe progesterone too. I’m hating the insomnia and weight gain since surgery and have thought of trying progesterone cream. Any thoughts?

  64. Hello, I`m 57 and post-menopausal around 53. I haven’t been on hormones accept some over the counter progesterone cream. I have vaginal dryness and UTI’s. I do have hot flashes but not as severe as a few years ago. I was thinking of asking my Dr. to prescribe bioidentical estrogen and progesterone. From your article it sounds like I`m to old to start them. Please tell me what you think. I really feel like I need something now. Should I just do progesterone?

    Thanks, Robin

    • You’ve only been in menopause for 4 years so you’re probably still in the safe window. But check with your doctor.
      Also, if it’s vaginal estrogen you’re thinking of, there’s no age limit for that. Vaginal estrogen is safe at any age. I should add that to the post.

      And just a tip: don’t use the word “bioidentical” with your doctor. Better to say something like “I’d like to try a vaginal estrogen.”

      Assuming she prescribes Vagifem, it is bioidentical or body-identical.

  65. I am 46 and a few years ago I began having very heavy periods with severe flooding and very short cycles, which have been helped by taking 200mg of micronized progesterone (cyclically) as well as some of your other supplement suggestions. However, I still had long, somewhat frequent periods with moderate flooding at least one day per cycle. About 2 months ago I had a Mirena IUD inserted and although spotty, I seem to be bleeding less and my NP says to be patient, that bleeding should decrease even more after 3 months.

    I reduced my progesterone dose to 100 mg, still cyclically, but I LOVE my “progesterone days” (sleep, reduced anxiety, etc.) and would like to take it continually so long as it’s safe (also considering the small amount of progestin acting locally in my uterus).

    Are there any considerations in combining Mirena with natural progesterone?

    Should I confirm that I’m having consistent anovulatory periods (by monitoring temperature?) before taking progesterone continually?

    What do you think about taking a 100 mg dose for days 1-14 and a 200 mg dose for days 15-28?

    My NP is not very knowledgeable about the benefits of natural progesterone (and didn’t understand why I wanted to continue taking it in addition to having the IUD inserted), but she has been open-minded to prescribing it as I wish.

    Thank you Dr. Briden for providing this amazing resource! I also loved your book.

    • Both good questions.
      In general, it is fine to take Prometrium along with hormonal IUD.
      As for continuous dosing, yes, that is usually fine for someone in their late-40s (and probably not ovulating very regularly anymore). But, of course, do speak to your doctor.

      thanks for commenting.

  66. Your articles are so helpful Lara – thank you. Do you have any advice for someone whose GP won’t prescribe progesterone and is pushing HRT instead? Unfortunately we are in an area with very limited doctors available, so changing GP sadly isn’t an option. My symptoms have improved with taking Mag+Taurine, DHEA-7 and Ashwagandha but feel I could still do with some extra support and would love to have options. Thanks so much!

  67. I’ve started using progesterone cream 3 months ago. I’m 45 with a monthly bleed (albeit, much lighter now) but I’m showing so many signs of low estrogen. I’m considering to go to a progesterone/ phytoestrogen cream (red clover) I’m not sure if I need bio estrogen yet. How do you feel about phytoestrogens?

    • In general, phytoestrogens are beneficial. Before menopause, they have an anti-estrogen effect.
      After menopause, phytoestrogens can a mildly pro-estrogen effect but it’s mild. And may not be enough to relieve dryness or flushes or insomnia.

  68. Thank you!! The hormone profiles are so expensive here in the US.

    Also, thank you for not using scare tactics to convince women that hormone therapy is the ONLY way to go. I’ve read so many books/watched videos by doctors who tell women that if they don’t use some form of therapy during peri- to give years post menopause they will develop some awful life-threatening chronic disease. Is there a difference culturally between the rest of the world and the US? It seems that many doctors based on the US use fear based tactics to convince patients to take drugs/unnecessary therapies. Been thinking of this a lot lately.

  69. I finally found a wonderful Dr knowledgeable about women’s hormones – yay! I had a hysterectomy about a year ago at age 38 due to adenomyosis and a rare uterine anomaly that caused pain. Based on my symptoms and family history of early menopause (mom was age 40 when she completed menopause), we both think that I am in perimenopause. I have been prescribed Prometrium for symptom management. We are starting at a dose of 200mg (which I know is a bit higher than your recommended 50-100mg starting dose) due to my severe insomnia and anxiety, night sweats, and endometriosis diagnosis (endo was excised at same time as hyst for adenomyosis).

    My questions:

    1. When is continuous dosing with bio-identical progesterone generally recommended vs cyclical dosing? I had to pour through Dr Prior’s website, and it sounded like migranes, perimenopause, and endo are times when perhaps daily dosing is warranted – is that correct?

    2. Would a daily dose suppress ovulation?

    • more than 200 mg per day can potentially suppress ovulation, but that’s not always a bad thing with endometriosis. Also, if you’re now in your 40s, then you might not be ovulating regularly anyway.

      Short answer: it can be okay to dose daily (continuously) if that is what your doctor prescribed.

      Other situations would call for cyclic or luteal phase dosing only.

  70. What about just using progesterone cream? I can’t afford to go to the doctor and have my hormones tested. I have in last years, but unless something shows up as “low,” doctors aren’t keen to prescribe anything. I have anovulatory cycles more often than not now. Thank you –


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