How long do I need to stay on the HRT?

Short answer:  As long as it takes.

Long Answer:  Because all women are so different, women will vary tremendously in how long they will be menopausal.  While on HRT, women will not know when they are over it, and the path tests will not reveal the end of menopause either. The only way to know is to stop the hormones and see what happens. If the symptoms return, it means you are still menopausal and need to continue on the BHRT. If there are no symptoms on stopping the BHRT, then it may mean menopause is over. The symptoms can vary on the time it takes to return – in some women they may start immediately, and some may only return months after stopping the HRT. Recent research is encouraging women to stay on HRT long-term, as it reduces the risk of osteoporosis, heart disease and memory and brain function deterioration. (See under “Menopause recommendations” above.


What is the difference between BHRT or natural HRT, and the standard HRT?

See the chapter headed: Natural HRT and Synthetic HRT – The facts for a full explanation. To claim natural hormones are better and safer then the alternative, we have to go on research and evidence, acceptable to the medical profession.  This means proper studies from the top medical institutions by the acknowledged experts in the field.  This is what I have provided.


Are there any side effects related to taking troches?

Side effects are extremely  uncommon but do occur even with natural hormones. The most common side effects are gum irritation from the troche, occasionally fluid retention when initally commencing the troche. I recommend rinsing your mouth out after using the troche. Sometimes you can react to some other substance in the troche – like the sweetener (either Stevia, a herb, or saccharin, which some chemist use). Breast tenderness is quite common, and is related to excess oestrogen. Bloating and fluid retention is due to excess Progesterone. Irritability, acne andexcess hair growth may mean too much testosterone.


Are their any other methods of taking bio-identical hormones apart from troches?

Hormone can also be incorporated in a slow release capsule. This tends to be used if women have a gum irritation from the troche or if they find the taste of the troche unpleasant.Hormones can also be incorporated in a cream but from experience I have found troches and capsules are more effective than creams and dosage can be more accurately controlled. See section labelled troches on this website.


I have read several books and articles suggesting saliva testing is more accurate than blood testing to monitor hormone levels?

This is an interesting question and depends which doctor you consult for bio-identical hormones. From my own experience over the last 10 years I have used both methods but from personal choice now favor blood testing. Blood tests have to be done at specific times as the level of hormone in the blood does vary according to when the troche or capsule is taken. All the major menopause associations are against salivary testing of hormones.

Salivary testing of hormones is not covered by Medicare in Australia. The reason is that the expert committee appointed to make these decisions have come to the conclusion that there is no validity to salivary testing of hormones, no scientific evidence in favour of it, and so it is a waste of money.

This is the opinion of the American College of Gynecologists:

The American College of
Obstetricians and Gynecologists XXXXX SW
PO Box 96920
Washington, DCNNN-NN-NNNN

There is no evidence that hormonal levels in saliva are biologically meaningful. Whereas saliva is an ultrafiltrate of the blood and in theory should be amenable to testing for “free” (unbound) concentrations of hormones, this has not proved to be the case (4). The problem with salivary testing and monitoring of free hormone levels is twofold: 1) there is no biologically meaningful relationship between salivary sex steroidal hormone concentrations and free serum hormone concentrations and 2) there is large within patient  variability in salivary hormone concentrations (5–9). Salivary hormone levels vary depending on diet, time of day of testing, the specific hormone being tested, and other variables (6, 7, 10–12).

Here is one of many research papers showing the reason why:

Ann Clin Biochem. 2009 May;46(Pt 3):183-96. doi: 10.1258/acb.2008.008208. Epub 2009 Jan 28.

Salivary steroid assays – research or routine?


Department of Chemical Pathology, Southampton University Hospitals Trust, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK. pjwendo@btinternet.com


Salivary concentrations of unconjugated steroids reflect those for free steroids in serum although concentrations may differ because of salivary gland metabolism. Samples for salivary steroid analysis are stable for up to 7 days at room temperature, one month or more at 4 degrees C and three months or more at -20 degrees C. When assessed against strict criteria, the evidence shows that salivary cortisol in evening samples or following dexamethasone suppression provides a reliable and effective screen for Cushing’s syndrome. Sequential salivary cortisol measurements are also extremely helpful for the investigation of suspected cyclical Cushing’s syndrome. There is potential for the identification of adrenal insufficiency when used with Synacthen stimulation. Salivary 17-hydroxyprogesterone and androstenedione assays are valued as non-invasive tests for the home-monitoring of hydrocortisone replacement therapy in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

The diagnostic value of salivary oestradiol, progesterone, testosterone, dehydroepiandrosterone and aldosterone testing is compromised by rapid fluctuations in salivary concentrations of these steroids. Multiple samples are required to obtain reliable information, and at present the introduction of these assays into routine laboratory testing is not justified.

This is the view of the US FDA (Food and Drug Administration, a body set up to protect and promote peoples health):

 Is saliva testing helpful for people taking menopausal hormone therapy?

Some compounding pharmacies and other promoters of “BHRT” claim that estrogen levels in a person’s saliva can be tested by practitioners to help practitioners estimate the amount of hormone a person needs and purportedly to “customize” the hormone therapy for individual patients. There is no scientific basis for using saliva testing to adjust hormone levels. Instead, practitioners should adjust hormone therapy dosages based on a patient’s symptoms.

Here is more evidence:

Maturitas. 2002 Jan 30;41(1):1-6.

Caution on the use of saliva measurements to monitor absorption of progesterone from transdermal creams in postmenopausal women.


Steroid and Immunobiochemistry Laboratory, Canterbury Health Laboratories, P.O. Box 151, Christchurch, New Zealand. john.lewis@cdhb.govt.nz



To determine the levels of progesterone in plasma, red cells and saliva as well as pregnanediol-3-glucuronide excretion in postmenopausal women using transdermal progesterone creams.


A double-blind placebo controlled study was carried out using 24 postmenopausal women. Creams (placebo, 20 or 40 mg progesterone/g) were applied twice daily for 3 weeks followed by 1 week without before a further 3-week treatment. Morning samples were collected at 0, 1, 3, 4, 7 and 8 weeks for analysis.


There were small increases in plasma progesterone levels and pregnanediol-3-glucuronide excretion compared to the placebo group and red cell progesterone levels never exceeded plasma levels during progesterone cream use. Saliva progesterone levels were very high and variable in the progesterone cream groups compared to the placebo group and presented a paradox to the usual relationship observed between plasma and saliva progesterone in premenopausal women.


The absorption of progesterone from transdermal creams is low and we caution against the use of saliva measurements to monitor progesterone absorption. The low systemic absorption of progesterone may not be due to peripheral conversion by 5 alpha-reductase(s). We also conclude that the low level of progesterone associated with red cells suggests they are not important in the delivery of progesterone to target tissues.

More :

Climacteric. 2000 Sep;3(3):155-60.

Effect of sequential transdermal progesterone cream on endometrium, bleeding pattern, and plasma progesterone and salivary progesterone levels in postmenopausal women.

Wren BG, McFarland K, Edwards L, O’Shea P, Sufi S, Gross B, Eden JA.


Sydney Menopause Centre, Royal Hospital for Women, Barker Street, Randwick, New South Wales 2031, Australia.


Hormone assay indicated that physiological levels of estradiol were achieved, but progesterone levels were insufficient to induce any detectable change in the endometrium. Only one patient experienced bleeding during the study period. Levels of salivary progesterone were so variable as to be considered completely unreliable in determining the potential influence on biological activity.


My doctor says “Bio-identical HRT” is untested and unsafe, and compounding chemists are not to be trusted.

Here is a comment from the FDA (Food and Drug Admin) USA:

Pharmacy Compounding

1. What is pharmacy compounding?

FDA regards traditional pharmacy compounding as the combining or altering of ingredients by a pharmacist, in response to a licensed practitioner’s prescription, to produce a drug tailored to an individual patient’s special medical needs. In its simplest form, traditional compounding may involve reformulating a drug, for example, by removing a dye or preservative in response to a patient allergy. In the case of menopausal hormone therapy, an FDA approved progesterone product contains peanut oil. Progesterone compounded without peanut oil in response to a prescription for a specific patient who is allergic to this ingredient might allow the patient to safely use the drug.

2. Is combining two or more drugs considered compounding?

FDA would consider the combining of two or more FDA-approved drugs into a single medication, in a manner not described in a drug’s FDA-approved labeling, to be compounding if it is done by a pharmacist in response to a licensed practitioner’s prescription and produces a medication tailored to an individual patient’s special medical needs.

3.  Is pharmacy compounding beneficial for patients?

It can be.  Traditional pharmacy compounding enhances patient treatment with individually-tailored drugs when a physician deems that an FDA-approved drug may not be available or appropriate for that patient’s care.  Thus, traditional compounding is an important component of patient care.

I have presented many studies from many experts on this website proving that BHRT is safe, has been fully tested and researched, and has the approval of most of the top Menopausal and endocrine societies. How much more does your doctor want? This nonsense about “compounding chemists” is hard to understand. These chemists are your normal chemists who have passed all their exams like any other chemist. They are regulated and checked regularly by the authorities like any other chemist. We trust our chemists when they prepare medicines for us. When I was a child, my doctor would write a script such as ” 1 ml xyz, 2 drops abc, 1 gm cde. Prepare with 5ml glucose solution Make up 100 ml. Take 5 ml daily” Most scripts were compounded then – we did not have the ready made mass produced factory produced products of today. Finally, how difficult is it to weigh and make up 2mg Oestrogen? Not much room for error.

This brings us to a bigger issue – the misinformation and  about the whole BHRT and natural hormone industry. Some of which is run by people with ties to various pharmaceutical companies. They often shower doctors with gifts and to influence their loyalty. I have seen this same play many times over the years in medicine -vested interests desperate to preserve their influence. This website is devoted to try and help women get a clearer picture of the science behind the various choices they make when using hormones.


Does testosterone have side effects?

The most common side effects observed with testosterone are hair growth and acne. In my experience these side effects occur in approximately 3 out of 10 women. These effects are reversible on ceasing the testosterone. 70% of women who take testosterone have no side effects.


Are there risks factors with respect to breast cancer from taking bio-identical hormones?

For medicolegal purposes we have to assume risk factors for bio-identical hormone replacement are similar to those associated to using synthetic HRT. However there are some studies suggesting bio-identical oestriol which is used as the majority of the estrogen in troches is perhaps safer than synthetic estrogen. This combined with blood testing to ensure the minimum amount of estrogen is used to control symptoms would perhaps confer an increased level of safety when using bio-identical hormone replacement. Further studies are probably necessary to confirm the above information. See the section labelled Safety of BHRt, and the section on BHRT and comparison to synthetic HRT on this website.


Does it matter which compounding chemist I use?

Yes, it matters greatly. They are not the same. It takes a commitment to have invested in the best equipment, buy the top quality ingredients, have professionally trained staff. Not all chemists do this.


My doctor says I do not have to have progesterone because I had a hysterectomy. Is this correct?

Strictly speaking, your doctor is correct. One of the main actions of progesterone is to protect the uterus from some of the potential harmful effects of estrogen. However, the synthetic progestogens have some nasty side effects, including risk of breast cancer and stroke.  The natural progesterone does not have this risk. We now know that natural progesterone has very positive effects on the nervous system, which makes it worth having anyway. My attitude is that if the normal balance of hormones in women over the years has included estrogen, progesterone and testosterone, then the body will function best with that balance restored.


Wont taking HRT just delay menopause, and cause me to have it anyway when I stop the HRT?

Just as putting coloring in your hair as you go grey (grrr), does not change the process of greying – just covers it up – so taking HRT does not change the process. It still happens anyway.  All you are doing is masking the nasty effects of menopause until it goes away.  HRT helps to make the process bearable.


I am on BHRT and have just had a period – the first for some time? What does it mean?

Menopause is characterized by permanent cessation of menstrual periods and is clinically diagnosed after 12 months of complete amenorrhea. It occurs at a median age of 51 years alongside the physiological process of aging, although it can happen at an earlier age for other medical conditions or after surgery (surgical menopause). Due to reduced circulating estrogens and progesterone, the reproductive organs undergo progressive atrophy. This physiologic process of aging is also present at an endometrial level; without the cyclic hormonal actions of the menstrual cycle, the endometrium during menopause becomes atrophic. Postmenopausal bleeding (PMB) is a common gynecologic complaint encountered by the clinician. Endometrial cancer is present in about 10% of patients with PMB. Nevertheless, many other conditions, such as endometrial or cervical polyps, genital atrophy, or non-gynecologic conditions, may also be present. Historically, dilation and curettage (D&C) was the main diagnostic procedure in patients with PMB; however, newer methods of investigation have replaced D&C


How do I use the progesterone cream:

It all depends on whether you are still having periods or not.

If having periods, then you will start on about day 10-12 of the cycle (Day 1 is the day you start bleeding) with 1/2 ml daily until day 16. Then 1 ml daily until day 20. Then 2 mls daily until day 26. Your next period should start soon after and you repeat the whole cycle again.

If you do not have a period, then you use 1ml daily. If a period appears all of a sudden, then use as above.

If, at any time, a period comes early or during the cycle unexpectedly, stop the cream and restart the cycle all over again.

Rub the cream into the forearms, shoulders, upper chest, abdomen, upper legs. Move it around from day to day. Do not put it into areas of cellulite (Hips mainly) as it will not absorb well into cellulite.

Remember, progesterone is very safe used in this way, so the doses can vary, as can the dates, in order to get the best response.


I worry about you retiring and you will have no-one to replace you.

No-one is indispensable (although I would like to think I am!). However, my health is good, I enjoy the work I do, and intend to continue to do this for many years yet. When the time comes, I will look around and hopefully, find someone to replace me. There are other doctors that practice BHRT so that is another option people have.

Any more questions on BHRT, please feel free to comment below.

  1. Sureetha Blackwell

    Hi. I live in Perth and was hoping you could recommend a BHRT specialist. The specialist I’m currently seeing has prescribed troches which don’t appear to be working . I have been on them for 6 months having previously been on them 5 years prior when they worked excelllently so I know how well you feel when your hormones are properly balanced. I have not lost any weight I’m the heaviest I have ever been bloated and uncomfortable and lack motivation. Any recommendations for a specialist here in Perth would be greatly appreciated. Cheers.

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