BHRT, examined: who it is for and who it is not

Bioidentical hormone replacement has generated a lot of controversy over the last two decades. Dr Galy has prescribed it for more than 20 years, and it is now well accepted that the terms "bioidentical" and "body-identical" describe the same hormone molecules. Body-identical HRT is now widely used as a first-line treatment for menopause symptoms, and hormone replacement is also used for other hormone deficiencies in women and men. What it is not is either the panacea its proponents claim or the risk its detractors describe. It is a medical treatment: useful for a defined group of patients, and safe for most of them when it is appropriately dosed and monitored. This article sets out who falls into which group and what treatment at 23MD involves.

What does "bio-identical" / "body-identical"mean?

Bioidentical or body-identical HRT means replacement with hormones structurally identical to those the body produces: the same molecules, rather than molecules whose chemical structure is different from, or only similar to, human hormones. The term is overused in marketing and under-defined in clinical discussion. We use it precisely.

So it is important to know that bioidentical and body-identical hormones refer to the same group of hormones. Both terms describe hormones, such as oestradiol, progesterone and testosterone, that are chemically and molecularly identical to those naturally produced by the human body. In UK practice, "body-identical" is usually used for licensed products, to distinguish them from compounded ones.

The confusion arises not from the hormones themselves, but from how they are prescribed.

These hormones may be supplied either as licensed, commercially manufactured medicines or as pharmacy-compounded preparations, individually formulated to meet a patient's specific clinical requirements.

In the UK, licensed medicines need a prescription from a doctor, and licensed body-identical HRT is widely available, including from your GP. If you need a compounded preparation, this is permitted under established regulatory guidelines. Doctors must normally prescribe licensed medicines where suitable. However, a compounded preparation may be prescribed when there is a specific clinical need that cannot be adequately met by an available licensed medicine, such as a particular dose, formulation or ingredient requirement. The prescribing doctor must be satisfied that there is sufficient evidence or clinical experience to support its use, explain its unlicensed status and associated considerations to you, and take responsibility for appropriate monitoring and follow-up.

Both licensed and compounded preparations can contain exactly the same hormone molecules. The distinction is whether your individual prescription contains licensed products, compounded preparations, or a combination of both.

At 23MD, Dr Galy will explain the available options and recommend the most appropriate treatment based on each patient's individual clinical needs, with licensed preparations preferred wherever suitable and compounded preparations considered where clinically justified.

What BHRT is not: a wellness supplement, an anti-ageing programme or a performance aid. It is prescription medicine, with the obligations that go with it.

Who is BHRT for?

Two groups. Women in perimenopause and post-menopause with significant symptoms and a hormonal picture that supports treatment. Men with confirmed hypogonadism, verified on two separate morning blood panels. Both groups must first complete a full cardiovascular and oncological review.

Women. The common indications are hot flushes and night sweats, sleep disturbance, low mood and anxiety linked to the menopausal transition, joint aches, vaginal dryness and loss of libido. Symptoms usually improve within a few days or weeks of starting HRT, and oestrogen also protects bone density, which matters most when periods stop before 45. In women over 45 the diagnosis of perimenopause is usually made on symptoms; blood tests inform dosing and rule out other causes rather than "prove" the menopause.

Men. Testosterone deficiency is a clinical diagnosis supported by biochemistry, not a number on its own. Guidance is clear that a single low reading is not diagnostic: testosterone should be measured in the morning, before 11 am, on two separate occasions, and interpreted alongside symptoms, with pituitary hormones, prolactin, thyroid function and ferritin checked to find the cause.

Both. Before either group starts, we review cardiovascular risk (blood pressure, lipids, clotting history, family history) and oncological risk (breast, prostate and endometrial history, and a personal or family history of cancer). Where something needs investigating, that happens first.

Who is BHRT not for?

Patients seeking performance enhancement. Patients with an active hormone-sensitive malignancy. Patients unwilling to follow the monitoring schedule the prescription requires.

In practice this also excludes, or requires specialist discussion before treatment: women with a history of breast cancer, who are usually advised against HRT; men with an unevaluated raised PSA or prostate abnormality, a haematocrit above 0.50, severe heart failure or a wish to preserve fertility, each of which NHS guidance lists as a contraindication to testosterone; and anyone with unexplained bleeding, a breast lump or a prostate symptom that has not yet been investigated.

What are the benefits and the risks?

For most women under 60 with symptoms, the benefits of HRT outweigh the risks. The figures are worth knowing:

• Combined HRT (oestrogen with a progestogen) is associated with around five extra cases of breast cancer per 1,000 women who take it for five years; the risk rises with longer use and falls after stopping, I
• Combined HRT (oestrogen and micronised bioidentical progesterone has not been shown to raise breast cancer risk in the same way as oestrogen with a synthetic progestogen. It is now generally accepted that this is the safest combination of HRT to prescribe.
• Oestrogen-only HRT carries little or no additional risk.
• Oestrogen taken as tablets slightly raises the risk of blood clots and stroke
• Oestrogen taken transdermally through the skin as a patch, gel or spray does not, which is why transdermal routes are often preferred.

For men, the main risks of testosterone treatment are a rise in red cell count (polycythaemia), which is why haematocrit is monitored, and the acceleration of an existing prostate cancer. Testosterone does not cause prostate cancer, but it can promote the growth of one that is already present, which is why PSA is checked before and during treatment.

Evidence for some of the wider claims made for hormone therapy, on longevity itself, cognition and long-term cardiovascular protection, is limited and in places contested. We do not make those claims. We treat symptoms and measured deficiency, and we are candid about the rest.

What does the monitoring schedule look like?

A baseline panel. A six-week review. A twelve-week panel. Thereafter, an annual review; a full blood panel is sometimes, but not always, needed. With this monitoring, it is an established medical treatment that can be used with confidence over the long term.

The baseline establishes where you start: hormone levels, full blood count, lipids, liver function, PSA for men, plus blood pressure and weight. The six-week review is clinical, covering how you feel, side effects and bleeding patterns, and allows an early dose adjustment. The twelve-week panel checks that levels have landed where intended and that nothing unexpected has moved. The annual review repeats the full panel, revisits risk and asks whether continuing remains the right decision. Patients who miss reviews are asked to come in before further prescriptions are issued. This is not bureaucracy; it is the thing that makes the treatment safe.

What to expect at a 23MD hormone consultation

The first consultation with Dr Galy takes a full history, covering symptoms, menstrual or sexual history, sleep, mood, medications and family history of cancer and cardiovascular disease, and arranges blood tests if they have not been done. The results are reviewed with you, the options (including the option of not treating) are explained, and a written plan with its monitoring dates is agreed before any prescription is issued.

The honest position

BHRT is an effective and well-tolerated treatment for the right patient. The skill lies in dosing, advice and monitoring over time. That is what 23MD offers.

Discuss hormone treatment with Dr Galy

If you recognise yourself in the first group, or are unsure which group you fall into, a consultation with Dr Martin Galy is the right starting point. You can read more about BHRT at 23MD, including BHRT for women and BHRT for men.

Book a consultation by WhatsApp: London or Dubai.

This article is for general information and is not a substitute for an individual consultation. Hormone treatment is prescribed only after assessment by a doctor.