Hormone Replacement, Done Medically
What Bioidentical Hormone Replacement Is
Bioidentical hormone replacement therapy prescribes hormones molecularly identical to the estradiol, progesterone, and testosterone the body makes, treating confirmed hormone decline: perimenopause and menopause symptoms like hot flashes and broken sleep in women, and confirmed low testosterone in men. At Howarth Plastic Surgery, a plan is written only after a medical evaluation and full lab panel rule out conditions that mimic hormone decline, such as thyroid disease and sleep apnea, with doses rechecked every 3 to 6 months.
Bioidentical hormone replacement therapy, or BHRT, is the prescription of hormones that are molecularly identical to the estradiol, progesterone, and testosterone the body makes, to treat symptoms caused by a confirmed decline in those hormones. In women that decline is perimenopause and menopause: hot flashes, night sweats, broken sleep, vaginal dryness, mood change, and the brain fog and fatigue that follow poor sleep. In men it is hypogonadism, low testosterone confirmed on morning blood tests, with low libido, fatigue, loss of muscle, and low mood. At Functional Wellness at Howarth Plastic Surgery, the Scottsdale practice of board-certified plastic surgeon Ashley Howarth, MD, FACS, BHRT starts with a medical evaluation and a full lab panel, not a symptom quiz. A plan is written only when the labs confirm a deficiency and rule out the conditions that mimic one, most often thyroid disease, iron deficiency, sleep apnea, and depression. Doses are rechecked with labs and a symptom review every 3 to 6 months. The delivery method is chosen at the consultation. Hormone symptoms rarely travel alone, so the same evaluation also asks about weight, and many patients pair BHRT with medical weight loss under one monitoring schedule.
The honest framing matters more here than for any other service on this site. The Menopause Society’s 2022 position statement concludes that for symptomatic women younger than 60 or within 10 years of menopause onset who have no contraindications, the benefits of hormone therapy most likely outweigh the risks, and that risk changes with the type of hormone, the dose, the route, the duration, and the timing of the start. The word bioidentical describes the molecule, not the safety: FDA-approved estradiol patches and gels and oral micronized progesterone are bioidentical, and the FDA states it does not have evidence that compounded bioidentical hormones are safer or more effective than approved ones. Howarth Plastic Surgery does not promise that BHRT reverses aging, prevents heart disease, or replaces treatment for depression, and it does not prescribe hormones to a woman with a history of breast cancer, unexplained bleeding, or a blood clot. Where hormones and skin overlap, in hair thinning and dry skin after menopause, the concern pages explain what BHRT can and cannot be expected to change.
Why Patients Ask About BHRT
What Patients Who Ask About Hormone Replacement Notice
Most people who ask Howarth Plastic Surgery about hormone replacement do not arrive with a diagnosis. They arrive with a cluster of changes that began over one or two years and that no single doctor has put together: sleep that breaks at 3 a.m., a temper that surprises them, a waistline that grew without a change in habits. These are the findings the team hears most.
- Waking hot at night, or waking at 3 a.m. and not falling back asleep
- Hot flashes during meetings, workouts, or a Scottsdale summer afternoon
- Brain fog, lost words, and a shorter fuse than a year ago
- Weight that settled at the waist despite the same diet and exercise
- Low libido, vaginal dryness, or in men, fewer morning erections
- Thinning hair at the part and skin that is suddenly dry and crepey
Every one of these has a hormonal cause and at least one non-hormonal cause, which is why the evaluation is a medical workup rather than a prescription. When labs confirm the deficiency, BHRT treats the cluster together; when they point somewhere else, the honest answer is a different treatment or a referral.
Where to Start
Who BHRT Is For, and What Happens First
BHRT at Howarth Plastic Surgery is for women in perimenopause or menopause with symptoms that affect sleep, mood, temperature regulation, sexual function, or daily function, and for men with symptoms of low testosterone confirmed on at least two morning blood tests, who have no history of a hormone-sensitive cancer, unexplained bleeding, blood clot, stroke, or heart attack, and who are willing to return for labs every 3 to 6 months. The first visit is a medical evaluation. A licensed provider under Dr. Howarth’s direction takes a full history, including menstrual pattern, cancer history in the patient and the family, clotting history, cardiovascular risk, sleep, mood, medications, and current supplements, records weight, blood pressure, and waist circumference, and orders a lab panel: estradiol, FSH, total and free testosterone, SHBG, TSH and free T4, a complete blood count, ferritin, fasting glucose and HbA1c, a lipid panel, vitamin D, and PSA in men. Men’s testosterone is drawn fasting before 10 a.m. and repeated on a second morning before any diagnosis is made. Women with a uterus who will take estrogen are also prescribed progesterone. A woman whose fatigue turns out to be a thyroid problem gets a thyroid answer, and a patient whose weight is the main driver of symptoms is offered medical weight loss first or alongside.
Dr. Ashley Howarth, MD, FACS is a board-certified plastic surgeon and an instructor in plastic surgery at Mayo Clinic. Functional Wellness is a service of her practice, Howarth Plastic Surgery, at 7373 N. Scottsdale Road, Suite C150, Scottsdale, Arizona 85253.
Three Hormones, One Workup
How Bioidentical Hormone Replacement Is Used in Scottsdale
Estradiol and Progesterone for Perimenopause and Menopause
Systemic estradiol, the most effective treatment for hot flashes and night sweats, is paired with progesterone to protect the uterine lining and typically improves sleep and flashes within 2 to 6 weeks.
Systemic estradiol is the most effective treatment for hot flashes and night sweats, and it also treats vaginal dryness and prevents the bone loss that accelerates after menopause. The Menopause Society’s 2022 position statement supports it for symptomatic women younger than 60 or within 10 years of menopause onset who have no contraindications, at the lowest dose that controls symptoms, reviewed at least annually. A woman with a uterus takes progesterone with it to protect the uterine lining. Oral micronized progesterone taken at night often improves sleep on its own. Sleep and flashes usually change within 2 to 6 weeks; mood and energy over 2 to 3 months. The route and product are chosen at the consultation, and the trade-offs of each are explained there.
Testosterone for Men With Confirmed Hypogonadism
Testosterone is prescribed only to men with consistent symptoms and unequivocally low testosterone confirmed on two separate fasting morning blood draws, with PSA and hematocrit reviewed before starting and rechecked at 3 to 6 months.
The Endocrine Society’s 2018 guideline sets the bar: testosterone is prescribed only to men with consistent symptoms and unequivocally low total testosterone on at least two separate fasting morning draws. Low libido, fatigue, reduced muscle, and low mood with normal labs get a different answer, and sleep apnea, obesity, and some medications are excluded first because they lower testosterone on their own. Before treatment, PSA, hematocrit, and a prostate history are reviewed; men who want to father children are not started, because testosterone suppresses sperm production. Hematocrit and PSA are rechecked at 3 to 6 months and then yearly. Energy and libido change over 3 to 6 months; body composition changes take longer and require training.
What Bioidentical Means, and What It Does Not
Bioidentical means the hormone molecule matches what the body makes (not that it’s natural, custom, or safer), and FDA-approved products, unlike compounded creams or pellets, have been through safety and dosing studies.
Bioidentical means the hormone molecule matches the one the body makes. It does not mean natural, plant-derived, custom, or safer. FDA-approved estradiol patches, gels, and vaginal preparations and oral micronized progesterone are bioidentical products that have been through safety and dosing studies. Compounded preparations, including creams and pellets mixed to a custom dose, have not; the FDA states it does not have evidence that they are safer or more effective, and both ACOG and the 2020 National Academies review reached the same conclusion. Howarth Plastic Surgery explains that distinction plainly, chooses the product and route at the consultation, and does not promote saliva testing or custom dosing as a safety advantage.
When Hormones Meet the Mirror: Weight, Skin, and Hair
Because menopause shifts fat toward the waist and reduces skin collagen and hydration, hormone-related weight gain and skin or hair changes are evaluated alongside medical weight loss, PRF hair restoration, and MOXI rather than treated with hormones alone.
Hormone change and appearance overlap, and a plastic surgeon’s practice can address both without confusing them. Menopause shifts fat toward the waist and lowers the calorie cost of daily life, so weight that will not move despite good habits is evaluated for medical weight loss, which can run alongside BHRT under one lab schedule. Estrogen loss reduces dermal collagen, skin thickness, and hydration, so dry, thinning skin and hair thinning at the part are common complaints; BHRT can help when a deficiency is confirmed, but it is not prescribed for skin or hair alone, and those concerns are also directed to PRF hair restoration, MOXI, and the skin laxity guide when the answer is treatment of the skin itself.
At a Glance
BHRT at a Glance
The questions patients ask most about bioidentical hormone replacement at Howarth Plastic Surgery, the short answer, and the source the answer rests on; individual plans are set after labs.
| Question | Answer | Source |
|---|---|---|
| Who is it for? | Symptomatic women in perimenopause or menopause without contraindications, best supported under age 60 or within 10 years of menopause onset; men with symptoms plus low testosterone on two morning draws | The Menopause Society 2022; Endocrine Society 2018 |
| What is prescribed? | Estradiol, progesterone for women with a uterus, and testosterone; the delivery method is chosen at the consultation | Practice protocol under Dr. Howarth's direction |
| Is bioidentical safer than conventional? | No. FDA-approved estradiol and micronized progesterone are bioidentical; the FDA, ACOG, and NASEM found no evidence that compounded versions are safer or more effective | FDA; ACOG Clinical Consensus No. 6, 2023; NASEM 2020 |
| What is checked first? | Estradiol, FSH, total and free testosterone, SHBG, thyroid, blood count, ferritin, HbA1c, lipids, vitamin D, PSA in men, and a cancer, bleeding, and clotting history | Practice protocol; Endocrine Society 2018 |
| How often are labs rechecked? | At 6 to 12 weeks, then every 3 to 6 months in the first year, then at least annually; hematocrit and PSA in men on testosterone | Endocrine Society 2018; practice protocol |
| Who is not a candidate? | Anyone with a history of breast, endometrial, or prostate cancer, unexplained vaginal bleeding, a blood clot, stroke, or recent heart attack, active liver disease, or pregnancy; men with elevated hematocrit, untreated severe sleep apnea, or a desire for fertility | The Menopause Society 2022; Endocrine Society 2018 |
By Symptom
Symptoms and What Testing Shows
The symptoms that bring patients to Howarth Plastic Surgery for hormone evaluation, the hormones assessed, the non-hormonal causes the lab panel is designed to exclude, and the step that usually follows.
| Symptom | Hormones assessed | Other causes ruled out | Typical next step |
|---|---|---|---|
| Hot flashes and night sweats | Estradiol, FSH | Thyroid disease, medication effect, infection, rarely carcinoid or lymphoma | Systemic estradiol with progesterone if a uterus is present; non-hormonal options after breast cancer |
| Broken sleep and 3 a.m. waking | Estradiol, progesterone, testosterone in men | Sleep apnea, alcohol, caffeine, anxiety, restless legs | Nighttime micronized progesterone; sleep study if snoring or apnea is suspected |
| Fatigue and brain fog | Estradiol, FSH, testosterone | Hypothyroidism, iron deficiency, B12 deficiency, depression, sleep apnea, prediabetes | Treat the cause found; BHRT only when the labs confirm a deficiency |
| Weight gain at the waist | Estradiol, testosterone, SHBG | Hypothyroidism, insulin resistance, cortisol excess, medications, calorie surplus | Medical weight loss alongside or instead of BHRT |
| Low libido, vaginal dryness, or erectile change | Estradiol, total and free testosterone, SHBG, prolactin in men | Depression, relationship factors, medications, diabetes, vascular disease | Local or systemic estradiol in women; testosterone in men only after two low morning draws |
| Mood change and irritability | Estradiol, progesterone, testosterone | Depression, anxiety, thyroid disease, sleep loss | BHRT when deficiency and sleep loss drive it; referral for mental health care when they do not |
| Hair thinning at the part | Estradiol, testosterone, SHBG, DHEA-S | Iron deficiency, thyroid disease, recent illness or surgery, medications | Treat the cause; hair thinning guide and PRF hair restoration |
| Dry, thin, crepey skin | Estradiol | Hypothyroidism, Arizona humidity below 15 percent, over-cleansing, retinoid irritation | Dry skin guide, medical skincare, HydraFacial, MOXI in laser season |
A Visit Built Around Your Labs
What to Expect at a BHRT Consultation at Howarth Plastic Surgery
A BHRT consultation at Howarth Plastic Surgery has three parts: a medical history and examination, a lab panel drawn that day or at a nearby lab, and a follow-up visit where the results are reviewed and a plan is written or a different diagnosis is explained. The first visit takes about 45 to 60 minutes; the results visit about 30.
History, exam, and the contraindication screen
A licensed provider under Dr. Howarth’s direction reviews your symptoms and their timeline, menstrual history or erectile and libido history, personal and family cancer history, any blood clot, stroke, or heart attack, sleep and snoring, mood, medications, and supplements, and records weight, blood pressure, and waist circumference. A hormone-sensitive cancer history, unexplained bleeding, or a clotting history ends the BHRT discussion and starts a different one.
A full panel, and for men a second morning draw
Blood is drawn fasting in the morning: estradiol, FSH, total and free testosterone, SHBG, TSH and free T4, complete blood count, ferritin, fasting glucose and HbA1c, lipids, vitamin D, and PSA in men. Men with a low first testosterone return for a second morning draw, because the Endocrine Society requires two low values before a diagnosis. Abnormal thyroid, blood count, or PSA results are addressed before any hormone is prescribed.
Results reviewed, dose and route chosen, rechecks scheduled
At the results visit the provider explains what the labs show, whether BHRT is indicated, which hormones and the starting dose, the delivery method chosen for you, the risks specific to your history, and what will not change. You leave with a written plan, a symptom log, and lab rechecks booked at 6 to 12 weeks and then every 3 to 6 months.
Clear Information. Informed Choices.
Safety and Limitations of Bioidentical Hormone Replacement
Hormone therapy is safe for most symptomatic women under 60 or within 10 years of menopause onset and for men with confirmed hypogonadism, when the contraindications are respected and the dose is monitored, and it carries real risks that depend on who takes it, what, and how. Systemic estrogen raises the risk of venous blood clots and stroke, more with oral than transdermal routes; estrogen with a progestogen taken for more than about five years is associated with a small increase in breast cancer risk; estrogen without progesterone in a woman with a uterus raises endometrial cancer risk, which is why progesterone is always paired. Testosterone in men raises hematocrit and can worsen sleep apnea and urinary symptoms, and its long-term cardiovascular safety is still being defined. Compounded preparations add a second layer of uncertainty about dose. That is why Howarth Plastic Surgery screens every patient against the contraindications, confirms deficiency with labs before prescribing, pairs progesterone with estrogen when a uterus is present, rechecks labs every 3 to 6 months, and refers anything outside its scope to primary care or a specialist.
Possible Side Effects Include
- Breast tenderness, bloating, headache, or spotting in the first weeks of estrogen
- Drowsiness or mood change with progesterone, usually why it is taken at night
- Acne, oily skin, fluid retention, or a rise in hematocrit with testosterone
- Skin irritation at a patch, gel, or injection site
- Rarely, a blood clot, stroke, or gallbladder disease with systemic estrogen
What Treatment Cannot Guarantee
- Weight loss without a nutrition and activity plan
- Relief of fatigue caused by thyroid disease, anemia, or sleep apnea
- Prevention of heart disease or dementia
- Safe treatment after breast, endometrial, or prostate cancer
- Thicker hair or firmer skin from hormones alone
What Happens After You Start
The First Year on Bioidentical Hormone Replacement
There is no downtime with BHRT, but there is a timeline, and knowing it prevents the two most common mistakes: stopping at week two because nothing has changed, and raising a dose at week four because something has. Hormone levels take weeks to settle and symptoms follow them in a predictable order. Sleep and temperature change first, mood and energy next, and body composition and sexual function last. Patients who also start medical weight loss follow both timelines on one lab schedule at Howarth Plastic Surgery.
You begin at the starting dose and route chosen at the consultation and keep a simple daily log of sleep, hot flashes, mood, and energy. Early side effects, breast tenderness, bloating, or spotting with estrogen, drowsiness with nighttime progesterone, acne or fluid retention with testosterone, are usually mild and usually settle. Nothing about the dose is changed in these two weeks, and any unexpected bleeding is reported the day it happens.
Night sweats and hot flashes typically ease within 2 to 6 weeks of systemic estradiol, and nighttime progesterone often improves sleep onset within the first month. Men on testosterone may notice a change in energy and mood in this window, although libido and body composition take longer. At the 6 to 12 week visit labs are repeated, the log is reviewed, and the dose is adjusted if symptoms persist or side effects outweigh the benefit.
Mood, concentration, and daytime energy usually improve over 2 to 3 months as sleep consolidates. Libido and vaginal dryness in women and libido, erections, and muscle response to training in men change over 3 to 6 months. Labs are repeated at the 3 to 6 month mark, including hematocrit and PSA in men, and the dose is held, reduced, or raised on the numbers and the log together. Skin dryness and hair shedding that were hormonal may begin to improve in this window.
Once symptoms are controlled on a stable dose, labs and a review continue every 3 to 6 months in the first year and at least annually afterward, with breast, pelvic, and prostate screening kept current with your primary care physician. The Menopause Society does not set an arbitrary stopping age; the decision to continue, taper, or stop is revisited each year against your symptoms, your risk, and your preference. Patients who also completed medical weight loss are evaluated for body contouring once weight is stable.
Surgeon-Directed Care
More Tools in the Toolbox: Why a Plastic Surgeon Directs Hormone Replacement
Functional Wellness is a service of Howarth Plastic Surgery, the Scottsdale practice of Ashley Howarth, MD, FACS, a board-certified plastic surgeon, a Fellow of the American College of Surgeons, and an instructor in plastic surgery at Mayo Clinic. The judgment a surgeon brings to hormone replacement is the habit of ruling things out before treating. A surgeon does not operate on a symptom; she operates on a diagnosis, and the same discipline applies here. Fatigue is not a testosterone level; it is a differential that includes thyroid disease, iron deficiency, sleep apnea, depression, and medication effects, and Dr. Howarth’s protocol requires that the labs and the history exclude those before a hormone is written. It also requires that the contraindications be treated as absolute: a woman with a breast cancer history, unexplained bleeding, or a prior clot is told no, clearly and early, and referred to a gynecologist or oncologist for the non-hormonal options that exist. A surgeon who manages bleeding and clotting risk before every operation applies the same caution to a prescription that changes both.
The second thing a plastic surgeon’s practice adds is honesty about what hormones change and what they do not. Patients arrive expecting BHRT to fix weight, skin, hair, and a tired face. Sometimes it helps; often the weight needs medical weight loss, the loose skin after that loss needs body contouring, the crepey neck needs physician-performed laser skin resurfacing or a facelift or neck lift, and the hair needs PRF rather than a higher estradiol dose. Because every one of those answers is available under one roof and evaluated by the same physician, no patient is sold hormones for a problem hormones will not solve. A licensed provider under Dr. Howarth’s direction delivers the day-to-day care; she sets the protocol and holds the line on who is a candidate. More tools in the toolbox, and an honest answer about which one you need.
SCOTTSDALE · MODERN OFFICE SETTING
Before & After
Bioidentical Hormone Replacement, Before and After Treatment
BHRT results are measured in a symptom log and a lab panel rather than a photograph: nights without a flash, hours of unbroken sleep, a testosterone level that moved from deficient to mid-normal, a hematocrit that stayed in range. Howarth Plastic Surgery reviews those numbers with you at every recheck. Where hormones and appearance overlap, the practice maintains before-and-after galleries for PRF hair restoration, MOXI, and body contouring after weight loss, and the team can show you the cases that match your concern during your visit.
Patient Case Summaries
Selected Bioidentical Hormone Replacement Case Summaries
These deidentified case summaries illustrate how the wellness team at Howarth Plastic Surgery evaluates and plans bioidentical hormone replacement in Scottsdale under Dr. Howarth’s direction. They include a woman in perimenopause, a man whose low testosterone was confirmed on two morning labs, a woman with a hormone-sensitive cancer history who was not a candidate, a patient whose fatigue turned out to be thyroid disease, a patient who combined BHRT with medical weight loss, and a patient whose hair thinning and dry skin improved and who was also referred to the skin concern guides. Each summary connects the patient’s presentation and assessment with the treatment provided or the recommendation made.
Case 01
Perimenopause
Night sweats, 3 a.m. waking, and irregular cycles in a woman still menstruating
Patient presentation
A woman in her late forties, a Scottsdale resident, reported eighteen months of night sweats, waking at 3 a.m. several nights a week, a shorter temper, and cycles that had become irregular. She had no cancer history, no clots, and a normal mammogram within the year.
Skin assessment
The assessment found classic perimenopausal vasomotor and sleep symptoms with an intact uterus. Labs showed a rising FSH with variable estradiol, normal TSH, ferritin, and blood count, and a normal HbA1c. Nothing in her history or labs was a contraindication.
Procedure performed
Low-dose transdermal estradiol with oral micronized progesterone at night, the route chosen at the consultation, with a symptom log and lab recheck at 8 weeks.
Clinical rationale
The Menopause Society’s 2022 position supports hormone therapy for symptomatic women within 10 years of menopause onset without contraindications; a woman with a uterus takes progesterone with estrogen, and nighttime progesterone addresses the sleep complaint directly.
Follow-up
Night sweats stopped by week four and she was sleeping through most nights by the 8 week visit; she continues on the same dose with rechecks every 6 months and annual screening with her gynecologist.
Case 02
Male hypogonadism
Low testosterone confirmed on two fasting morning draws before treatment
Patient presentation
A man in his fifties reported a year of low libido, fewer morning erections, fatigue, and a loss of strength in the gym despite consistent training, and asked for testosterone after reading about it online.
Skin assessment
A fasting draw before 10 a.m. showed low total testosterone, and a second morning draw a week later confirmed it, with normal PSA, hematocrit, and TSH. Sleep apnea screening was negative and he was not planning to father children.
Procedure performed
Testosterone replacement by the method chosen at the consultation, with hematocrit and PSA rechecked at 3 months and then every 6 months in the first year.
Clinical rationale
The Endocrine Society’s 2018 guideline requires consistent symptoms plus unequivocally low testosterone on at least two separate mornings, a normal prostate screen, and no untreated sleep apnea before starting; monitoring hematocrit and PSA is part of the same guideline.
Follow-up
Energy and libido improved over 3 months and his training response returned by 6; hematocrit rose modestly and remains within the practice’s threshold on a slightly reduced dose.
Case 03
Not a candidate
Severe hot flashes after breast cancer, and why the answer was a referral, not hormones
Patient presentation
A woman in her fifties who had completed treatment for estrogen receptor positive breast cancer three years earlier asked about BHRT for hot flashes that woke her several times a night and were made worse by the medication she took to prevent recurrence.
Skin assessment
The assessment identified a history of a hormone-sensitive cancer, an absolute contraindication to systemic estrogen at Howarth Plastic Surgery regardless of how the hormone is made or delivered. Her symptoms were real and severe, and the cause was clear.
Recommendation
No hormone therapy. She was referred back to her oncologist and gynecologist with a written summary of her symptoms and a list of the non-hormonal treatments for vasomotor symptoms that are used after breast cancer, so the conversation could start from her own team.
Clinical rationale
Bioidentical does not mean safe after a hormone-sensitive cancer; The Menopause Society, ACOG, and the FDA make no exception for compounded preparations, and a physician-directed practice says no early and clearly rather than treating a symptom around a diagnosis.
Follow-up
Her oncologist started a non-hormonal medication for hot flashes; she returned to the practice for skin care unrelated to hormones and reported that the flashes were manageable.
Case 04
Thyroid, not hormones
Fatigue, weight gain, and dry skin that were hypothyroidism, not low estrogen
Patient presentation
A woman in her early forties, new to Scottsdale from the Northwest, reported constant fatigue, a 15 pound weight gain, dry skin, and feeling cold in an air-conditioned office, and asked whether her hormones were declining early.
Skin assessment
Her cycles were regular and her estradiol and FSH were consistent with normal ovarian function. TSH was clearly elevated with a low free T4, and her ferritin was also low. The picture was primary hypothyroidism with iron deficiency, not perimenopause.
Recommendation
No sex hormone replacement. She was referred to her primary care physician for thyroid replacement and iron evaluation, with the full lab panel sent along, and invited back after treatment if any symptom remained.
Clinical rationale
Fatigue, weight gain, dry skin, and cold intolerance overlap almost completely with the symptoms attributed to menopause, and the lab panel exists to separate them; prescribing estrogen here would have delayed the correct diagnosis.
Follow-up
On thyroid replacement and iron her energy and skin returned to normal over 4 months; she did not need BHRT and chose a HydraFacial series for the skin dryness that remained through her first Arizona summer.
Case 05
BHRT with weight loss
Menopausal symptoms and 40 pounds gained since her forties, treated together
Patient presentation
A woman in her mid fifties, five years past menopause, reported hot flashes, poor sleep, low mood, and a weight gain of about 40 pounds over a decade that had settled at her waist, with a body mass index in the obese range and a recent diagnosis of prediabetes.
Skin assessment
The assessment confirmed postmenopausal estrogen deficiency with no contraindication to hormone therapy, an HbA1c in the prediabetic range, normal thyroid and blood count, and no personal or family history of medullary thyroid carcinoma or pancreatitis.
Procedure performed
Transdermal estradiol with nighttime progesterone, started first, and four weeks later a prescribed GLP-1 receptor agonist within the practice’s medical weight loss program with nutrition coaching and a resistance training plan, both monitored on one lab schedule.
Clinical rationale
Hormone therapy treats the flashes and sleep but does not produce weight loss on its own; in the STEP 1 trial semaglutide 2.4 mg produced a mean loss of about 15 percent of body weight at 68 weeks alongside lifestyle intervention, and starting the two four weeks apart made side effects attributable.
Follow-up
Her sleep normalized within the first month; over the following year she lost a meaningful share of her excess weight, her HbA1c returned to the normal range, and she was evaluated for body contouring once her weight had been stable for six months.
Case 06
Hair and skin
Thinning hair at the part and crepey, dry skin that improved on BHRT and were also treated directly
Patient presentation
A woman in her early fifties, two years past menopause, was most bothered by hair thinning at her part and by skin on her face and hands that had become dry, thin, and crepey within a year, and asked whether hormones would restore both. She also had night sweats she had been ignoring.
Skin assessment
The assessment confirmed postmenopausal estrogen deficiency with vasomotor symptoms and no contraindication. Ferritin, thyroid, and vitamin D were normal, so the hair shedding had no non-hormonal cause on labs. The scalp showed diffuse thinning at the part with no scarring, and the skin showed the reduced thickness and hydration expected after estrogen loss.
Procedure performed
Transdermal estradiol with nighttime progesterone for the vasomotor symptoms and the deficiency, with a clear statement that hormones were not prescribed for the hair or skin alone, plus referral to the practice’s hair thinning and dry skin guides, a PRF hair restoration series, and a MOXI series the following laser season.
Clinical rationale
Estrogen decline after menopause is associated with reduced dermal collagen, thickness, and hydration, and hormone therapy can help those tissues when a deficiency is confirmed, but the evidence does not support prescribing it for skin or hair as the indication; the skin and scalp are treated directly by the treatments built for them.
Follow-up
Night sweats resolved within a month, shedding slowed over 4 months, and after PRF and MOXI she reported denser hair at the part and skin that held moisture through the winter; she continues BHRT with rechecks every 6 months.
From First Visit to a Plan You Can Keep
Booking, Planning, and Follow-Up at Howarth Plastic Surgery
Functional Wellness at Howarth Plastic Surgery is a medical practice with a spa’s convenience. Established patients book online. New patients can book online or request a consultation, and the team responds usually the same day.
Online booking or a consultation request
Book a wellness consultation directly online, or request a consultation and describe your symptoms, when they started, and any cancer, clotting, or thyroid history. Arrive fasting in the morning if you would like labs drawn at the first visit.
A written plan built on your labs
You leave the results visit with a written plan: which hormones and the starting dose; the delivery method chosen for you; the risks specific to your history; what will change and when; whether medical weight loss runs alongside; and the dates of your lab rechecks.
Rechecks every 3 to 6 months, review every year
Labs and a symptom review at 6 to 12 weeks, then every 3 to 6 months in the first year, then at least annually, with screening kept current with your primary care physician. A-List members have the next recheck scheduled before they leave the last one.
Your Questions, Answered
Bioidentical Hormone Replacement Frequently Asked Questions
Bioidentical hormone replacement therapy is treatment with estradiol, progesterone, or testosterone that is molecularly identical to the hormones the body makes, prescribed to treat symptoms of a confirmed deficiency in perimenopause, menopause, or male hypogonadism. Bioidentical describes the molecule, not the safety. FDA-approved estradiol patches and gels and oral micronized progesterone are bioidentical; compounded creams and pellets are also bioidentical but have not been through the same safety studies.
BHRT treats symptoms caused by hormone deficiency: hot flashes, night sweats, broken sleep, vaginal dryness, mood change, and the brain fog and fatigue that follow poor sleep in perimenopause and menopause, and low libido, fatigue, low mood, and loss of muscle in men with confirmed low testosterone. It can help dry skin and hair thinning that are hormonal, but it is not prescribed for weight, skin, or hair alone.
It replaces the hormone that has fallen, at a dose that returns levels to the range where symptoms resolve. Estradiol acts on receptors in the brain’s temperature center, the vaginal tissue, bone, and skin; progesterone protects the uterine lining and aids sleep; testosterone acts on muscle, libido, and mood. Treatment starts with a lab panel, a starting dose, a symptom log, and rechecks at 6 to 12 weeks and then every 3 to 6 months.
For symptomatic women under 60 or within 10 years of menopause onset without contraindications, The Menopause Society’s 2022 position statement concludes the benefits most likely outweigh the risks. Risks are real: blood clots and stroke with systemic estrogen, a small rise in breast cancer risk with long combined use, and higher hematocrit with testosterone. Bioidentical does not mean safer; the FDA states it has no evidence compounded hormones are safer than approved ones.
Hot flashes and night sweats usually ease within 2 to 6 weeks of starting estradiol, and nighttime progesterone often improves sleep within the first month. Mood, concentration, and daytime energy improve over 2 to 3 months as sleep consolidates. Libido, vaginal dryness, and in men energy, libido, and muscle response take 3 to 6 months. Doses are not changed before the first recheck at 6 to 12 weeks.
Not necessarily. Some patients use BHRT for the years when symptoms are worst and taper off; others continue for bone and symptom benefit with annual review. The Menopause Society does not set an arbitrary age to stop; the decision is revisited every year against your symptoms, your risk profile, and your preference. Men with confirmed hypogonadism usually continue, with hematocrit and PSA checked at least annually.
Yes. At Howarth Plastic Surgery BHRT and medical weight loss are often run together on one lab schedule, typically started a few weeks apart so side effects can be attributed. Hormone therapy does not interfere with laser treatment, injectables, or PRF, and after major weight loss the same physician evaluates loose skin for body contouring. Hormones are never prescribed as a substitute for those treatments.
Women in perimenopause or menopause with symptoms that affect sleep, mood, temperature, or sexual function, and men with symptoms plus low testosterone on two fasting morning draws, who have no history of breast, endometrial, or prostate cancer, unexplained bleeding, blood clot, stroke, or recent heart attack, and whose labs have excluded thyroid disease, anemia, and sleep apnea. Men who want to father children are not candidates for testosterone.
Book a wellness consultation at Howarth Plastic Surgery in Scottsdale online or by request. The first visit is a medical history, examination, and a fasting morning lab panel; men with a low testosterone return for a second morning draw. At the results visit a licensed provider under Dr. Howarth’s direction explains what the labs show and, if BHRT is indicated, writes the plan, chooses the delivery method, and books your rechecks.
No. The molecule is the same whether it comes from an FDA-approved patch or a compounded cream, and the safety depends on the dose, the route, the duration, and your history, not the label. The FDA, ACOG, and a 2020 National Academies review all found no evidence that compounded bioidentical hormones are safer or more effective than approved products. Howarth Plastic Surgery explains that distinction at the consultation rather than marketing around it.
BEGIN HERE
Request a Consultation
Tell us what you are considering. A member of our patient care team will follow up with consultation availability and next steps.
Megan S.
Patient Coordinator
Prefer to talk or text?
Selected References
