The Role of Compounding in Hormone Replacement Therapy During Perimenopause

During perimenopause, women experience changing hormones, menstrual irregularities, and changing symptoms like hot flashes, night sweats, sleep disturbances, vaginal dryness, and sexual discomfort.¹ These symptoms often vary in severity and don’t follow a fixed sequence, so treatment requires an adaptable treatment plan rather than a rigid, fixed approach. 

Hormone replacement therapy (HRT) can help manage these symptoms, and an important part of each HRT treatment plan is reassessing effectiveness and patient adherence after beginning therapy and periodically afterwards. The Endocrine Society recommends an initial follow-up 1 to 3 months after starting menopausal hormone therapy, followed by visits every 6 to 12 months depending on the individual patient.² As part of this ongoing monitoring, the HRT combination, dose, regimen, administration route, delivery, and duration may need to be tailored to each individual woman.  

A compounding pharmacy may become involved at any point during this process. For example, a patient may initially receive an FDA-approved hormone therapy but later find that available products are either in shortage or do not meet their specific needs, and their prescriber may determine that a compounded medication is necessary. 

Collaboration Between Prescribers and Compounding Pharmacists

When a prescriber determines that an FDA-approved medication cannot meet an individual patient’s specific needs, work with a compounding pharmacist to prepare an appropriate alternative compounded formulation. As part of this process, prescribers should communicate the clinical rationale for compounding, the dose, the route of administration and dosage form, allergies, and a plan to monitor the patient’s response to the compounded medication. 

The compounding pharmacist can then evaluate ingredient compatibility, formulation stability, and potential limitations that may affect the suitability of the compounded medication. Then, the prescriber should monitor the patient during follow-up visits to see how they respond to the treatment and can work with a compounding pharmacy to adjust the dose or dosage form as needed depending on any symptoms the patient presents. 

If a change is needed (such as due to an adverse event to a hormone therapy), the prescriber can consult with a compounding pharmacist to prepare an updated formulation. This iterative collaboration between the patient, prescriber, and compounding pharmacy allows a patient’s response to a treatment to be reassessed as a patient needs change as perimenopausal symptoms evolve.

Shortage of Commercially Available Estrogen Patches

This collaboration between prescribers and compounding pharmacists may also be relevant when supply disruptions limit access to a patient’s prescribed estrogen formulation. There is currently a reported shortage of commercially available estrogen patches because more women have sought treatment for symptoms of menopause after a 2025 FDA labeling change that removed boxed warnings for breast cancer, cardiovascular disease, and probable dementia. The FDA has stated that estrogen patches are technically available and that manufacturers are increasing line capacity, but there are reports of backorders and intermittent shortages of several brands.

Although the FDA has not yet officially declared an estrogen patch drug shortage, if this changes, compounding pharmacies can fulfill transdermal estrogen patch prescriptions. In the absence of an official drug shortage, patients may still need compounded estrogen patches for other reasons, including:

• Allergy to an ingredient in available estrogen patches: Some estrogen patches contain propylene glycol, hydroxypropyl cellulose, or ethanol,³ which have been suggested to cause contact dermatitis in some case reports.^4–6 A compounded patch can be formulated without the offending ingredient.
• Need for a dosage not commercially available: A compounded preparation may be needed if a patient requires a lower estrogen dose than what can be obtained from commercially available patches. Drug-release characteristics depend on the specific delivery system, and cutting a patch compromises some patches. Instead, prescribers can consult a compounding pharmacy to determine whether a suitable customized formulation can provide the lower dose that an individual patient needs.

Partnering with VLS Pharmacy for Compounded HRT

VLS Pharmacy and New Drug Loft provide prescribers with compounded HRT therapies for these and other scenarios during perimenopause and menopause. As 503A pharmacies, we provide customized compounded medications using pharmaceutical-grade APIs sourced from PCCA. We support providers and patients throughout the changes that come with perimenopause and beyond. 

Please comment below with any thoughts or questions.

Reach out to our team to learn about best practices and to partner with our experts on custom compounded medications for your patients. All medications from VLS Pharmacy and New Drug Loft are prepared in a lab that follows safety and quality standards per our status as a 503A pharmacy.

References

1. Vaginal and Urinary Symptoms of Menopause | Patient Information | JAMA | JAMA Network. Accessed October 14, 2026. https://jamanetwork.com/journals/jama/fullarticle/2614191
2. Stuenkel CA, Davis SR, Gompel A, et al. Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015;100(11):3975-4011. doi:10.1210/jc.2015-2236
3. Estraderm® FDA Product Label. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/019081s043lbl.pdf
4. Kaur G, Woodruff CM, Botto N. Life after patch testing: Allergic contact dermatitis caused by propylene glycol in Vivelle transdermal estradiol patch. JAAD Case Rep. 2021;9:34-35. doi:10.1016/j.jdcr.2021.01.002
5. Schwartz BK, Clendenning WE. Allergic contact dermatitis from hydroxypropyl cellulose in a transdermal estradiol patch. Contact Dermatitis. 1988;18(2):106-107. doi:10.1111/j.1600-0536.1988.tb02753.x
6. Barbaud A, Trechot P, Reichert-Penetrat S, Schmutz J. [Contact dermatitis due to ethyl alcohol: how to perform patch tests?]. Ann Dermatol Venereol. 2000;127(5):484-487.

 

 

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