Choosing a dosage form for BHRT: cream, capsule or troche

Bioidentical hormones are structurally identical to the hormones the body makes. That part is settled by the molecule. How much reaches the bloodstream, how quickly, and what the liver does to it first is decided by the route.

	Cream	Capsule	Troche
Route	Through the skin	Swallowed	Dissolved against the cheek
First-pass liver metabolism	Largely avoided	Yes	Partly avoided
Consistency	Varies with site and technique	Most predictable dosing	Varies with technique
Main watch-out	Transfer to others	Liver effects of oral estrogen	Peaks; part is swallowed

Creams (transdermal)

Hormone creams are absorbed through the skin directly into circulation, avoiding first-pass metabolism in the liver. That makes transdermal delivery a common choice for estradiol, particularly where the effects of oral estrogen on the liver are a concern.

• Absorption depends on the application site, skin condition, the cream base and how consistently the patient applies it.
• Transference is the main practical risk. Patients should wash their hands after applying, let the area dry, and avoid skin contact with partners, children and pets until it has absorbed.
• Evidence that topical progesterone cream provides endometrial protection is limited. When endometrial protection is needed, many prescribers choose oral micronized progesterone instead.

Capsules (oral)

Capsules offer the most predictable dosing and are simple for patients to take. Oral micronized progesterone is widely used, and is often taken at bedtime because it can cause drowsiness. Compounded progesterone is also available in sustained-release capsules, designed to smooth out peaks.

Oral estradiol is processed by the liver before reaching circulation, which affects clotting factors and binding proteins. Observational data associate oral estrogen with a higher risk of venous thromboembolism than transdermal routes — one reason transdermal estradiol is often preferred in patients with elevated risk.

Troches (buccal)

Troches are small lozenges held between the cheek and gum until they dissolve. Part of the dose is absorbed through the lining of the mouth; part is inevitably swallowed and absorbed orally. Onset is fast, and levels tend to peak and fall more sharply than with creams.

• Technique matters: patients should let the troche dissolve fully without chewing, and avoid eating or drinking until it has.
• Troches can be useful when a patient does not want a cream or cannot swallow capsules.

Other forms

For local symptoms, vaginal preparations of estriol or estradiol deliver hormone where it is needed with lower systemic exposure. Ask us about other forms if none of the three above fits a patient.

A note on FDA-approved options

Several bioidentical hormones are available as FDA-approved products, including estradiol patches and gels and oral micronized progesterone. Compounding is most valuable when a patient needs a strength, combination or dosage form that is not available commercially. Compounded medications are not FDA-approved.

Not sure which form fits a protocol? Our pharmacists are glad to talk it through. See our hormone preparations.