Natural Hormone Replacement Therapy: What “Natural” Really Means and What Works

What is natural hormone replacement therapy?

Search for natural hormone replacement therapy and you will find three very different things sold under the same word. Some people mean prescription hormones that match the ones your body made. Some mean plant extracts that act a little like estrogen. Others mean managing menopause without any hormones at all. Each has a different evidence base, so it helps to know which one you are looking at.

When a clinic or website offers “natural HRT” or “natural hormone therapy,” it almost always means the first group: bioidentical hormones, often compounded.

Are bioidentical hormones actually natural?

Bioidentical hormones have the same chemical structure as the estradiol and progesterone your ovaries make. That is the sense in which they are “natural.” They are not extracted from your body or from food. They are made in a lab, usually starting from plant compounds found in soy or wild yam that are chemically converted into human hormones.

That conversion only happens in a lab. Your body can't turn wild yam into progesterone. In a small placebo-controlled trial, a wild yam cream used for 3 months did not change progesterone or estradiol levels and had no meaningful effect on symptoms compared with placebo (Komesaroff 2001).

The opposite of bioidentical is not “chemical” but “structurally different.” Conjugated equine estrogens (Premarin) and synthetic progestins such as medroxyprogesterone acetate have different molecules from your own hormones. We compare them side by side in bioidentical vs. synthetic hormones.

Which hormone replacement therapy products are bioidentical and FDA-approved?

Many people assume that natural hormone therapy has to come from a compounding pharmacy. It doesn't. Several standard prescriptions are bioidentical:

• Estradiol as a skin patch, gel, spray, oral tablet, vaginal cream, vaginal tablet or vaginal ring.
• Oral micronized progesterone, which its label describes as chemically identical to progesterone of ovarian origin. Note that the brand-name capsule contains peanut oil (Prometrium label).
• A combined estradiol and progesterone capsule, approved for hot flashes in women who have a uterus (Bijuva label).

These products have been through FDA review for safety, effectiveness and manufacturing quality. Generic versions are often covered by insurance.

Compounded bioidentical hormones

Compounded hormones are mixed by a pharmacy for one person's prescription. That allows doses, combinations and forms that aren't sold commercially, such as estradiol and progesterone in a single cream, or estriol. But compounded products are not FDA-approved, are not reviewed for safety or effectiveness, and don't come with a standard label listing their risks.

ACOG's 2023 clinical consensus says compounded bioidentical hormone therapy should not be prescribed routinely when FDA-approved formulations exist. It also cites testing in which most compounded products were within 10% of their labeled strength, but some were as much as 26% below label for estradiol or 31% above label for progesterone (ACOG 2023). In a US survey, 86% of women didn't know that compounded hormones are not FDA-approved (Pinkerton 2015).

By the numbers

Compounded hormones: strength and awareness

26%below labeled strength for estradiol in some compounded products testedSource: ACOG 2023

31%above labeled strength for progesterone in some compounded products testedSource: ACOG 2023

86%of surveyed US women didn't know compounded hormones aren't FDA-approvedSource: Pinkerton 2015

There can still be good reasons to choose compounding, such as an allergy to an ingredient in a commercial product or a strong preference for one cream instead of two products. Just choose it for those reasons, not because it is labeled natural.

Is natural hormone therapy safer?

“Natural” describes where a molecule's design came from. It doesn't tell you about safety. Estradiol is estradiol, and its main risks apply whether it is called bioidentical, natural or neither. Here is what the evidence supports:

• The route matters a lot. In UK records covering more than 80,000 women with blood clots, oral HRT was linked to higher clot risk, while estrogen through the skin was not (overall adjusted odds ratio 0.93). Among oral products, estradiol carried somewhat lower risk than conjugated equine estrogens (Vinogradova 2019).
• The progestogen may matter. In the French E3N cohort, estrogen combined with micronized progesterone was not linked to higher breast cancer risk over the follow-up period, while estrogen with synthetic progestins was (Fournier 2008). This is observational data, and longer use may still carry some risk.
• The basics still apply. The Menopause Society says hormone therapy risks depend on type, dose, how long you use it, the route, your age when you start and whether a progestogen is used (Menopause Society 2022). If you have a uterus, you still need progesterone to protect the lining from estrogen. Breast cancer, past blood clots, stroke and unexplained bleeding are still reasons for caution or avoidance.
• Compounded products are the least studied. Most of their research is small and short, and pharmacies aren't required to report side effects the way drug makers are (ACOG 2023).

So a well-studied “natural” combination exists: estradiol through the skin plus oral micronized progesterone, both FDA-approved. A compounded cream is a different product with less data behind it.

Do plant-based natural hormones work?

Plant estrogens (phytoestrogens) such as soy isoflavones and red clover have a structure that loosely resembles estrogen and bind weakly to estrogen receptors. They are not hormone replacement, and the evidence that they relieve hot flashes is weak.

In a 12-month randomized trial, hot flashes and night sweats fell by 34% with black cohosh, 57% with red clover and 63% with placebo, compared with 94% on hormone therapy. Only the hormone therapy did significantly better than placebo (Geller 2009). The Menopause Society does not recommend supplements, herbal remedies, soy foods or soy extracts for hot flashes (Menopause Society 2023).

That big placebo response is worth knowing about: hot flashes vary week to week, so almost anything can seem to help at first. If you want the details on soy, red clover and black cohosh, see our guide to natural estrogen replacement and our review of menopause supplements.

Can you manage menopause naturally without hormones?

Yes, for many women, especially if symptoms are mild. The Menopause Society recommends cognitive behavioral therapy and clinical hypnosis for hot flashes, with weight loss supported by more limited evidence. Prescription nonhormone options include certain SSRI or SNRI antidepressants, gabapentin, fezolinetant and oxybutynin (Menopause Society 2023).

Sleep routines, regular exercise, strength training and limiting alcohol help overall health in midlife, even though they haven't been shown to stop hot flashes on their own. Our guide to managing menopause naturally covers these in more depth.

What lifestyle changes can't do is replace estrogen in tissues that depend on it. Vaginal dryness, pain with sex and bone loss after menopause usually need a medical treatment if they are bothering you or putting you at risk.

Who is natural hormone therapy right for?

Bioidentical hormone therapy tends to suit women who:

• Have bothersome hot flashes, night sweats or sleep disruption from menopause.
• Are under 60 or within about 10 years of their last period, when The Menopause Society considers the benefit-risk balance favorable for most healthy women (Menopause Society 2022).
• Prefer hormones that match their own, or want to avoid older oral regimens.

How to start natural hormone replacement therapy

Step by step

How to start natural hormone therapy

1. 1Write down your symptomsAnd how much they affect sleep, work and relationships.
2. 2Gather your historyIncluding your last period, any cancers, clots, migraines, heart disease and current medications.
3. 3Ask a licensed clinician about FDA-approved bioidentical options first.Estradiol through the skin plus oral micronized progesterone is a common starting point.
4. 4If you prefer a compounded product,Ask why it suits you better, how the lining of the uterus will be protected and how follow-up will work.
5. 5Review after about 3 monthsAnd then at least yearly. Dosing is based on symptoms and side effects; ACOG doesn't recommend saliva or blood hormone tests to adjust it.

Amie offers one option: Amie HRT+, a compounded cream that combines estradiol and progesterone, with the strength chosen by a licensed clinician after an online review of your health history. Like all compounded hormones, it is not FDA-approved. The clinician decides whether it is appropriate for you, and FDA-approved patches, gels and progesterone capsules from your own doctor are a strong alternative.

The bottom line