Compounding Pharmacy Hormones for Perimenopause: What You Need to Know Before You Go That Route

The Promise of Personalized Hormones

You may have heard that compounded hormones are more natural, more tailored to your body, or somehow better than standard hormone therapy. That message is everywhere in wellness spaces.

The truth is more layered. Compounding pharmacies can provide real value in specific situations. But the marketing often overstates the personalization and understates the tradeoffs.

If you are navigating hormone therapy decisions during perimenopause, you deserve a clear picture of what compounding actually is, and when it genuinely makes sense.

What Compounding Actually Means

Compounding is the practice of a licensed pharmacist creating a custom medication formulation. Instead of dispensing a standardized manufactured product, a compounding pharmacy combines ingredients to a specific dose, form, or combination prescribed by your provider.

This has been a legitimate part of pharmacy practice for a long time. It exists for real reasons. Some patients need doses that commercial products do not offer. Some people have allergies to inactive ingredients in standard formulations. Some medications are not available commercially anymore.

For hormones, compounding typically means making creams, gels, troches (dissolve-under-the-tongue lozenges), capsules, or pellets with specific hormone types and doses. Common compounded hormones include estradiol, estriol, progesterone, testosterone, DHEA, and sometimes combinations of several at once.

How Compounded Hormones Differ from FDA-Approved HRT

FDA-approved hormone therapy products have been through clinical trials demonstrating safety and efficacy. Their manufacturing is regulated. Their dosing is standardized and verified. When you fill a prescription for an FDA-approved estradiol patch, you know the dose is consistent every time.

Compounded hormones are not subject to the same FDA oversight. They are regulated at the state level through pharmacy boards, and the quality varies between pharmacies. The FDA does not verify that a compounded product contains the stated dose, is stable over its shelf life, or is free from contamination.

This does not mean all compounding pharmacies are low quality. Some are excellent and some hold voluntary accreditation through organizations like PCAB (Pharmacy Compounding Accreditation Board). But the variability is real, and you cannot assume quality is uniform the way you can with a commercially manufactured product.

The Bioidentical Overlap

Compounded hormones are often marketed as bioidentical, and this is where the terminology gets confusing.

Bioidentical means the hormone molecule is identical in structure to what your body produces. This is actually a description of the hormone molecule itself, not whether it was compounded or commercially manufactured.

FDA-approved estradiol patches, gels, and sprays are also bioidentical in structure. Prometrium, the FDA-approved oral progesterone, is also bioidentical. So the word bioidentical does not automatically mean compounded, and compounded does not automatically mean superior.

When marketing conflates compounded with bioidentical, it creates the impression that FDA-approved options are somehow less natural or less compatible with your body. That framing is misleading. The molecule is the molecule, regardless of where it was made.

The Pros of Compounding

There are genuinely good reasons to use compounded hormones in specific circumstances.

Custom dosing. If you need an estradiol dose that falls between commercially available strengths, a compounding pharmacy can make that exact concentration. This can be useful when fine-tuning is genuinely needed.

Combination formulas. Some patients benefit from having estradiol and progesterone in a single topical preparation. That combination is not available in commercial products, but a compounding pharmacy can make it.

Alternative delivery forms. If you cannot tolerate the adhesive in patches, or you need a sublingual option, or you want a rectal suppository for localized absorption, compounding can accommodate forms that standard products do not offer.

Testosterone for women. Because no FDA-approved testosterone product exists for women in the US, compounding is often the primary route for women who need low-dose testosterone therapy. This is one of the strongest genuine use cases for compounding in perimenopause care.

The Cons and the Real Risks

Variable quality is the central concern. Without mandatory FDA manufacturing standards, the actual hormone concentration in a compounded product can differ meaningfully from what is on the label. Studies have found that some compounded hormone preparations contain significantly more or less hormone than intended.

This matters because hormone dosing precision is real. Too much estrogen without adequate progesterone increases endometrial cancer risk. Too much testosterone causes androgenic side effects. Getting a consistent dose every time is not just about efficacy. It is about safety.

There is also the issue of less clinical evidence. Large studies on hormone therapy have used standardized commercial formulations. When outcomes are studied and documented, they are based on those products. Extending those findings to compounded preparations with variable composition requires assumptions that may not hold.

Cost is another factor. Compounded hormones are typically not covered by health insurance, while many FDA-approved hormone products are covered at least partially. Out of pocket costs for compounded preparations can be significant over time.

The Testing-Compounding Loop to Be Cautious About

A pattern to watch for: some practices order saliva or specialized urine hormone tests, generate a detailed hormone profile, and then prescribe a custom compounded formula specifically designed around those results.

The appeal is obvious. It feels very personalized and scientific.

The concern is that the tests used in this model, particularly saliva testing, have well-documented reliability issues for guiding prescribing decisions. Hormone levels during perimenopause fluctuate dramatically from day to day. A single saliva test is a snapshot of one moment. Using it to build a custom hormone formula is not as precise as the process makes it feel.

If a provider recommends a compounded hormone protocol after saliva testing, it is reasonable to ask what the evidence base is for using those results to guide dosing, and why an FDA-approved option would not work for your situation.

When Compounding Makes Sense vs. Standard HRT

Standard FDA-approved HRT makes sense as a first-line option for most perimenopausal women considering hormone therapy. The evidence base is strong, the dosing is reliable, and insurance coverage may offset cost significantly.

Compounding makes more sense when a specific need cannot be met by commercially available products. You need a dose that does not exist in standard formulations. You have a confirmed allergy or intolerance to an ingredient in the commercial version. You need testosterone therapy (where compounding is often the only route in the US). Your provider has a specific clinical rationale that requires a non-standard combination.

Tracking your symptoms carefully before and after any hormonal change, whether standard or compounded, gives you real data on what is working. PeriPlan's symptom logging tools are designed to help you build that record so your provider can make adjustments based on your actual patterns.

The decision is not which category is better overall. It is which option meets your specific clinical needs with the most reliable delivery and the best evidence behind it.

Questions to Ask Your Provider

If your provider recommends compounded hormones, these questions are worth asking directly.

Why is a compounded formulation preferable to an FDA-approved option for my specific situation? What PCAB-accredited compounding pharmacy will you use? How will we monitor my levels and symptoms after starting? What is the plan if my levels are inconsistent? What is the evidence base for the dose you are recommending?

A provider confident in their recommendation will have clear answers. If the response is vague or focuses mainly on the idea that compounded hormones are more natural, that is a signal to ask more.

You are making a real medical decision. Your questions are appropriate, and a good provider will welcome them.

The Bottom Line

Compounding pharmacies serve a real and legitimate purpose in hormone therapy. Custom dosing, testosterone for women, and alternative delivery forms are genuine advantages in specific situations.

But the marketing around compounded hormones often overpromises on personalization and underplays the quality variability and lack of regulatory oversight. For most women starting hormone therapy during perimenopause, FDA-approved bioidentical options are a strong first step that should not be bypassed in favor of compounding by default.

Know the difference. Ask the questions. Make the decision based on what your body specifically needs, not which option sounds more tailored.

This content is for informational purposes only and does not replace medical advice. Always consult your healthcare provider about your specific situation.