BHRT, Explained: A Q&A with Dr. Stephanie Wallman

Bioidentical Hormone Replacement Therapy (BHRT) has become a popular option for women seeking support through perimenopause, menopause, and beyond. But with so much information—and misinformation—out there, it’s hard to know where to start.

We sat down with Dr. Stephanie Wallman, a functional medicine physician and Medical Director at The Lanby, to answer the most common questions she hears from patients.

Q: What is BHRT, and how is it different from traditional hormone replacement therapy?

BHRT stands for bioidentical hormone replacement therapy. Unlike traditional HRT, which uses synthetic hormones, BHRT uses compounds that are chemically identical to the hormones your body naturally produces. We use it to support brain, bone, and heart health as women age and move out of their reproductive years.

Q: When should someone start thinking about BHRT?

The conversation typically begins in perimenopause, but that doesn’t mean you start right away. Perimenopause is when symptoms like sleep disturbances, mood swings, and night sweats begin, often due to shifting progesterone levels. Sometimes we’ll start with oral progesterone alone, which can really help with sleep. Estrogen, which fluctuates more dramatically, is usually added later—closer to or after menopause.

Q: How do you determine when someone is ready for estrogen?

Estrogen has an unpredictable rise-and-fall pattern during perimenopause, so we typically wait until someone is 10–12 months without a period. At that point, we’ll check hormone levels—like FSH, LH, and estradiol—to see if it’s time to introduce estrogen, alongside continued progesterone.

Q: How is BHRT administered?

My go-to combination is:

• Estrogen via patch or topical cream
• Oral progesterone

This pairing is effective for symptom relief and long-term protection, especially for bone density and cardiovascular health. Some providers prefer other delivery methods, but this is what I’ve found to work best.

Q: Is it easy to get the dose right?

Not usually the first time! We titrate to symptoms, not just lab numbers. That means we start with a low dose and adjust over time based on how a patient feels. Tools like the DUTCH test, a urine hormone test, help us fine-tune the dose and ensure patients are in the therapeutic range for long-term benefit.

Q: Are all women candidates for BHRT?

Not everyone. We always screen for personal and family history of breast, ovarian, or uterine cancer. When monitored correctly and paired with progesterone, BHRT is considered safe—but it requires careful management.

Q: What are the risks of BHRT?

The most significant risk is increased risk of breast cancer if estrogen is prescribed without progesterone, or if hormone levels are not monitored appropriately. There can also be minor side effects like skin irritation from patches, or hormone transfer if using a topical cream and coming into contact with others.

Q: Why is it important to work with a PCP trained in BHRT? Can’t my OB-GYN prescribe it?

This is a big one. Just because your OB-GYN manages your reproductive health doesn’t mean they’re trained in BHRT. Most OB-GYNs aren’t formally trained in hormone optimization or advanced monitoring, and many don’t use tools like the DUTCH test. It’s important to work with a clinician who knows how to prescribe, titrate, and monitor BHRT safely.

Q: How often should I meet with my provider if I’m on BHRT?

Early on, we typically meet monthly or every three months to find the right dose. Once symptoms are under control and dosing is stable, visits are spaced out to every six to twelve months for maintenance and monitoring.

Q: Can lifestyle and nutrition support BHRT?

Absolutely. Your adrenal health becomes critical in menopause, since your adrenals are your main source of hormone production once the ovaries stop functioning. And metabolic health—especially insulin and blood sugar regulation—is also a major factor in how well you feel. BHRT works best when it’s paired with nutrition, movement, and stress management.

Q: How long can someone stay on BHRT?

You can be on it for life. Previous guidance suggested a 10-year limit, but that’s changed. New research shows that starting early—during perimenopause or soon after menopause—offers the most protective benefits. Most of my patients feel so good on BHRT, they tell me I’d have to “pry it from their cold dead hands!”

Q: What’s the difference between synthetic and bioidentical hormones?

There's a big difference. The Women's Health Initiative studied synthetic hormones (like progestins), which showed increased risk of cardiovascular disease and stroke. Bioidentical hormones, when monitored and paired correctly, do not carry the same risk profile and are often safer and more effective.

Q: Are there any resources you recommend to learn more?

Yes! I always recommend the book Estrogen Matters—it’s a great, evidence-based resource that helps debunk myths and explain the science behind hormone therapy.

Q: What happens if someone just stops taking BHRT one day?

There’s no danger in stopping cold turkey, but symptoms like vaginal dryness or sleep issues might return. Most women don’t want to stop once they feel the difference. But if someone is ready to come off, we can absolutely guide that transition safely.

Final Thoughts from Dr. Wallman:

"BHRT can be transformative for women navigating hormonal changes, but it has to be done thoughtfully, with the right testing, oversight, and education. It’s not a one-size-fits-all solution—but when it’s right, it’s really right."

If you’re curious about whether BHRT might be right for you, book a consultation with our team. We’ll review your history, run comprehensive labs, and build a personalized hormone strategy grounded in functional, preventative care.

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