One Size Fits Almost No One - The Truth About Hormone Optimization
Why Starting HRT Isn’t the Same as Optimizing It | What are Compounded Medications? | Bioidentical Hormones vs. Synthetic Hormones - What’s the Difference? | The Difference between Treatment and Optimization
It’s Never “Just a Prescription”
Why Details Matter More Than Most People Realize
A common frustration of new patients sounds something like this:
“I started HRT about a year ago. I’m better than I was, but not where I want to be. Sleep has improved some, but I’m still tired — and my focus isn’t as sharp as I’d hoped. How do I know if what I’m doing is even working?”
This is incredibly common.
And it’s important to say this clearly: Starting hormones is not the same thing as optimizing hormones.
Two women may both say they are “on progesterone.”
That does not mean they are receiving the same therapy.
Two women may both say they are “using testosterone.”
That does not mean they are receiving the same formulation, dose, or absorption and the response can be different.
In traditional settings, prescriptions are often sent to commercial pharmacies and submitted to insurance. In many cases, it is completely appropriate and something I do in my practice as well.
But commercial medications are built for population averages.
They come in limited doses. Limited delivery systems. Fixed release pattern. But, when you fall outside the average — which many women in perimenopause and menopause do — details, down to the milligram, matter.
Bioidentical vs Synthetic Hormone Replacement: What It Means
Let’s clarify an important foundation.
Bioidentical hormones are structurally identical to the hormones your body makes naturally. The molecular structure matches what your body recognizes - if we draw these molecules out on paper, they match exactly what your body makes – in science, that matters a lot. What this translates to is your body processing them the same way it would its own hormones. In short, bioidentical hormones are an exact copy of our own hormones and therefore send the same messages/signals.
That is very different from synthetic hormones, which are chemically modified compounds designed to mimic hormonal activity. They are not the same as what your body produces. Even small changes to the chemical structure of a hormone equates to different messaging - think of it like this, if you write an email and change 3 sentences, the message just changed, it could change the reader’s interpretation a little, or it could change the entire meaning. This is how hormones work, hormones are chemical messengers, they send signals, like email messages, that tell something in our body what to do, how to work. Synthetic hormones also carry different risk profiles.
Where Bioidentical Hormones Come From
Some bioidentical hormones are available at standard retail pharmacies in fixed strengths. Estradiol patches are a great example — and I use them often when they’re appropriate. Patches are great for some women, some women do much better with a vaginal application.
But many dosing needs fall between available strengths. Or require different release patterns. Or need alternate routes.
That’s where compounding pharmacies enter.
Compounding pharmacies are specialized pharmacies that prepare medications tailored to the individual patient. This allows us to customize:
Precise dosing (sometimes down to microgram adjustments)
Delivery route (topical, vaginal, sublingual, injectable)
Immediate vs sustained release
Clean bases without unnecessary dyes, fillers or chemicals we’re avoiding
Bases that are designed for absorption based on where it’s applied
Combination formulations when clinically appropriate
Compounding is not fringe medicine. It is individualized, thoughtful medicine.
Beyond the Prescription: Why Hormone Care Is More Than a Quick Fix
Every so often, I hear a version of the same question:
“Can you ‘just’ refill my testosterone?”
“I really only need progesterone.”
“Isn’t it just a simple hormone prescription?”
I understand where it comes from. In a world of online clinics, 15-minute telehealth visits, and morning news commercials promising you’ll “feel 20 again,” it can look easy. Click. Ship. Inject. Done.
But hormone therapy — done well — is anything but simple.
The message is tempting:
Low energy? Here’s testosterone.
Hot flashes? Here’s estrogen.
Brain fog? Try this patch.
But here’s the truth:
Hormones don’t operate in isolation. They are messengers inside a complex, dynamic system.
If we ignore:
Chronic stress
Poor sleep
Blood sugar instability and poor metabolic health
Nutrient deficiencies
Gut health
Toxin exposure
Inflammation
…then we’re practicing the same quick-fix medicine that keeps people stuck.
Hormone therapy can be life-changing.
But hormone therapy without context? In my opinion, that’s incomplete care.
The Testosterone Reality for Women
Here’s something many women are surprised to learn:
There is currently no FDA-approved testosterone product specifically designed for women in the United States.
So what are the options?
Use a compounding pharmacy to create a dose appropriate for female physiology.
Prescribe a male testosterone product off-label and attempt to adjust it down.
Off-label prescribing is legal and often clinically appropriate. We do it all the time in medicine.
But here’s the nuance:
Male testosterone gels were studied in men, maybe a 200lb man. The pump devices are designed to deliver doses for male physiology — often around 20 mg.
Most women require somewhere between 0.5–5 mg daily.
That means we are estimating. Dividing pumps visually. Adjusting based on approximation.
That is not precision and when we’re talking about hormones, details and dose absolutely matter.
Where you apply testosterone can make a big difference too - we talk about this and decide this with you. One important consideration is if you have or are around young kids or pets. Maybe you’re a teacher or a physical therapist doing hands on care? Androgel is typically applied to places like the inside of the arm, back of the knee. Testosterone in the right dose is good for you, it’s absolutely not something we want to expose growing kids to. And pets, if we apply, then go cuddle with our dog and the testosterone gets on them, you can have unintended transfer. These are details that often aren’t talked about when we have rushed visits but they matter a lot!
When we use compounded preparations, we can prescribe the exact milligram strength needed — and adjust gradually based on response, labs, and symptom changes. We also use a base that we know absorbs well.
That’s the difference between template dosing and tailored dosing.
The Progesterone Dead End (And Why It Doesn’t Make Sense)
Commercial oral progesterone is bioidentical — which is wonderful. But it only comes in two strengths: 100 mg and 200 mg. And it is immediate release.
What if a woman does better at 150mg? Or 125 mg? Or maybe we cycle dose, sometimes this works better in our younger patients. So at one point in your cycle we might choose one dose then during your cycle, you may need support that looks like 50mg.
Or needs sustained release to prevent the 3am wake-up cycle?
Or benefits from vaginal administration instead of oral due to mood sensitivity or things like PMDD?
If the only available doses are 100 or 200 mg, and neither works perfectly, some clinicians default to switching to a synthetic progestin.
But progesterone and progestins are not interchangeable. Remember what we said about change the molecule, change the messaging - this is SO IMPORTANT!
Progesterone is a neurosteroid. It converts to allopregnanolone, which interacts with GABA receptors and can support calming, sleep-promoting effects.
Synthetic progestins do not share that pathway. Some may even oppose it. Often synthetic progestins actually lower natural hormones.
If a woman does not tolerate a specific dose or route of progesterone, the logical next question is: What formulation or delivery method fits her physiology better?
Not: Let’s abandon progesterone entirely.
Compounding allows us to explore:
Lower or intermediate doses
Sustained-release formulations
Sublingual troches
Vaginal preparations
Different bases for better tolerance
That is thoughtful titration.
A Cooking Analogy (Because This Is How My Brain Works)
I want to be careful here to not minimize the seriousness of hormone care.
Hormones are not a hobby.
They are powerful biologic messengers. They influence brain chemistry, cardiovascular risk, metabolism, sleep architecture, and long-term disease prevention.
So yes — this is serious medicine.
But because I love to cook, this analogy makes sense in my brain. Think of hormone therapy like baking a cake.
If you use high-quality ingredients, measured precisely, mixed in the right order, baked at the correct temperature — you get something that turns out beautifully.
If you substitute ingredients that are “close enough,” eyeball measurements, skip a step, or change the timing — you still get a cake.
It just might be… fine.
A little dry.
A little flat.
Not quite what you hoped for.
And that’s often what I hear when women come to me for a second opinion.
“I’m on hormones… but I still feel off.”
“I thought I would feel better by now.”
“It’s better than before, but not great.”
You’re not failing therapy. You may just be working with approximations instead of precision.
Precise dosing — for you — matters.
Delivery system matters.
Release pattern matters.
Base and absorption matter.
Follow-up and thoughtful adjustments matter.
When we fine-tune those variables, the result can feel dramatically different.
And while the cooking analogy simplifies something far more complex, the core idea holds: Quality ingredients + precise measurements + thoughtful execution = better outcomes.
Your prescription might require a small amount of estradiol but a higher level of progesterone.
Your sister may need the reverse.
And your best friend may benefit from adding testosterone into the mix.
Same stage of life. Uniquely different physiology.
Hormone therapy deserves that level of time and care.
“Compounding Isn’t FDA Approved” — Context Matters
This is where controversy often enters but hear me out.
FDA-approved medications at retail pharmacies go through massive clinical trials — every single strength must be individually approved. That process is extraordinarily expensive. And natural hormones can’t be patented.
When you personalize a prescription — adjusting dose, combining hormones, changing base — it cannot go through that identical FDA approval pathway because every variation would require separate trials.
That does not mean the active hormone molecule is different.
The estradiol, progesterone, or testosterone used by reputable compounding pharmacies is the same bioidentical molecule found in FDA-approved products.
Compounding pharmacies operate under regulatory oversight:
503A pharmacies are regulated by state boards and follow USP standards.
503B outsourcing facilities are FDA-regulated and follow current good manufacturing practices.
Quality depends on the pharmacy you partner with — which is why I am very selective about who we use.
There is a vocal group of providers who insist on retail pharmacy products only. I understand their concern for safety and standardization.
But here’s the inconsistency:
Many of those same clinicians recommend male testosterone gels for women — which is off-label and requires a lot of estimation when talking about dosing. If we’re advocating for precision and physiology-driven care, that approach falls short.
Customization is not a workaround, compounding exists because human biology is variable. And compounded medications are safe options.
Insurance, Cost, and the Surprising Reality
Commercial pharmacy prescriptions are often covered by insurance — though copays can often be higher than expected.
Compounded medications are honestly rarely covered and many compounding pharmacies aren’t going to deal with the insurance hassle.
And here’s something many women discover: Sometimes paying out of pocket for a compounded prescription is actually less expensive than the insured copay at a retail pharmacy.
Insurance coverage does not automatically equal affordability.
Why This Matters for You
If you’ve been “on hormones” for months and still feel off, it doesn’t automatically mean hormones aren’t for you.
It may mean:
The dose isn’t optimized.
The release pattern isn’t right.
The absorption isn’t adequate.
The base is affecting delivery.
Testosterone is underdosed, overdosed or inconsistently applied.
Progesterone timing needs adjustment.
Thyroid or cortisol interactions are being overlooked.
Hormones do not work in isolation.
They interact with sleep, stress physiology, metabolic health, cardiovascular risk, body composition, and long-term disease prevention. At EverWell, we take the 30,000 foot view approach because we believe that’s good care that actually gets people well. If we ignore the systems that hormones work in, you stay stuck.
This is systems biology, how everything works together. Not “just” prescription writing.
The EverWell Philosophy and an Investment Worth Making
You can get a hormone prescription at many places.
But individualized dosing, route selection, release customization, monitoring, and strategic longevity planning require depth.
Compounded prescriptions are not about being alternative. They are about having the flexibility to practice medicine the way physiology actually works.
One size fits almost no one.
And if we’re going to do hormone therapy — we should do it precisely, thoughtfully, and in partnership and more than once a year at a 15-minute check in.
Because your health is not a transaction.
It’s a long-term investment in how you feel, how you function, and how you age.
EverWell may not be the cheapest option.
And that’s intentional.
Behind every visit, every lab review, every dose adjustment, and every follow-up message is time you don’t see:
In depth lab reviews
Continuing education in hormone science and longevity medicine to bring you the most up-to-date care
Careful selection of pharmacies and formulations
Communication with compounding pharmacists
Charting, compliance, and legal oversight (testosterone is a controlled substance and requires a special license, extra paperwork and monitoring)
Ongoing infrastructure that keeps your care safe and personalized
When we talk about “good” medications, we don’t mean fancy packaging.
We mean:
The right dose for you
The right route (oral, topical, vaginal, injectable)
The right base or delivery system
The right monitoring plan
The right adjustments over time because our bodies do change over time
That level of customization requires expertise and intention. Yes, you can go quick and you can likely find it cheaper.
But in most areas of life, we understand that shortcuts often produce shortcut results.
We invest in:
High-quality food
Gym memberships
Travel sports for our kids
Coffee that tastes better
Homes, cars, vacations
Yet when it comes to our health — the one thing that determines how we experience all of the above — we’re conditioned to believe it should be free or fully covered but that model is outdated.
Here’s the honest truth: The traditional insurance model was built for sick care — diagnosing disease and treating it once it exists. Kind of like car insurance, if you get in an accident, you’ve got insurance but if you need an oil change, or brakes , or new tires, that’s something worth investing in.
The current model was not built for optimization, prevention, longevity strategy, aging well, deep lifestyle coaching, advanced labs that allow us to predict disease long before it happens, personalized hormone fine-tuning. If you want reactive care, insurance does that well. If you want proactive wellness — that requires investment.
When you invest in your health, you show up differently.
You engage differently. You prioritize differently. You have a different confidence. And the results – how you feel – reflect that.
Our goal is simple but profound: To help you live better. Longer.
Because when your energy is steady, your brain is clear, your sleep is deep, and your body feels strong — everything else in your life expands.
Your relationships.
Your work.
Your confidence. Your joy.
Your health is not an expense.
It is the foundation everything else is built on.
Erica Finnan, AGNP-C
Founder, EverWell Center for Health & Longevity
Live Better. Longer.
Love the Way You Feel.