What BiEst is
BiEst combines estradiol, the main estrogen the ovaries make before menopause, with estriol, a weaker estrogen that circulates in only small amounts outside pregnancy. The National Academies of Sciences, Engineering, and Medicine (NASEM) describes estriol as “a far less potent estrogen” than estradiol. Other studies find estriol clearly active when taken by mouth or vaginally, so how much it does depends on the dose, the route and how long it is used.
Compounding pharmacies make BiEst as creams, capsules, troches and suppositories. The cream is the most searched form, applied to the skin once or twice a day. The ratio and strength are written on the prescription, and pharmacies list strengths from 0.5 to 5 mg per gram or more.
BiEst is often sold as “bioidentical.” FDA has approved estradiol products that are identical to the estradiol the body makes; estriol is the part that only compounding supplies. FDA’s 2008 announcement described “bio-identical” as a marketing term when it is used to imply a benefit, and FDA says it has no evidence that compounded “bioidentical hormones” are safer or more effective than approved hormone therapy.
What 80/20 and 50/50 mean in estradiol
The strength on a BiEst label is total estrogen, estriol plus estradiol, per gram. Multiply it by the estradiol share to see the estradiol dose.
| BiEst cream | Estriol per gram | Estradiol per gram |
|---|---|---|
| 80:20 at 2.5 mg/g | 2.0 mg | 0.5 mg |
| 50:50 at 2.5 mg/g | 1.25 mg | 1.25 mg |
| 80:20 at 5 mg/g | 4.0 mg | 1.0 mg |
| 50:50 at 5 mg/g | 2.5 mg | 2.5 mg |
So two creams labeled “2.5 mg” can differ in estradiol by 2.5 times. PepScribe’s pharmacy makes BiEst cream at 80:20 in 1, 2.5 and 5 mg per mL, and the prescription names which one.
FDA-approved estradiol products, for comparison:
| FDA-approved product | Estradiol per labeled dose | Estradiol per gram |
|---|---|---|
| EstroGel 0.06%, one pump | 0.75 mg in 1.25 g of gel | 0.6 mg |
| Elestrin, one pump | 0.52 mg in 0.87 g of gel | About 0.6 mg |
| Divigel 0.1%, single-dose packets | 0.25 to 1.25 mg | 1.0 mg |
| Evamist, one spray | 1.53 mg | Not given per gram |
| Estradiol patches (Climara, Vivelle-Dot) | 0.025 to 0.1 mg delivered per day | Not applicable |
Only part of what you rub on reaches your blood. Patch figures are what the patch delivers each day, while gel and cream figures are what you put on the skin. None of the US labels for these products states how much of the applied estradiol is absorbed; the UK licence for the same 0.06% gel puts it at about 10%.
The one trial that compared BiEst with an FDA-approved product shows why the label number is only a starting point. In a randomized, blinded 2013 study of 40 postmenopausal women, 80:20 BiEst cream at 2.0, 2.5 and 3.0 mg was compared with a 0.05 mg per day estradiol patch for 16 days. Estradiol exposure was much lower on the cream: 181 against 956 at 2.0 mg, and 286 against 917 at 2.5 mg. The 3.0 mg cream was not significantly different from the patch. Estriol levels stayed low in every group, mostly below what the test could detect. All three creams used one base, so the National Academies cautioned that the results do not carry over to every 80:20 formulation.
Is BiEst a reasonable choice? What the expert bodies say
Every major body that has reviewed compounded hormones sets the same order: FDA-approved therapy first, compounding when there is a specific reason.
- National Academies (2020, commissioned by FDA). Found “insufficient evidence to support the overall clinical utility” of compounded bioidentical hormones, and recommended limiting them to a documented allergy to an ingredient in an approved product or a documented need for a dosage form that is not available. “Patient preference alone should not determine the use of cBHT preparations.”
- The Menopause Society (2022). Consider compounded therapy only when a woman cannot use an approved therapy, for reasons such as an ingredient allergy or “a dose or formulation not currently available in government-approved therapies,” and document the reason.
- ACOG (2023). Compounded menopausal hormone therapy “should not be prescribed routinely when FDA-approved formulations exist,” while recognizing that compounded medicines “may be appropriate for some patients and in some circumstances.”
- The Endocrine Society. Sees no evidence-based medical need for compounded hormone therapy when an approved preparation is available.
The accepted reasons are concrete. ACOG’s example is an approved progesterone product that contains peanut oil: a compounded version without the peanut oil lets a woman with a peanut allergy use it. The other is a dose or form no approved product offers. Estriol is in no approved product, which is why BiEst exists only as a compounded medicine. Surveys put compounded hormone users in the US at 1 to 2.5 million women aged 40 and older.
The societies also agree on testing. Saliva and urine tests are not recommended for setting hormone doses, and The Menopause Society calls serum testing “rarely needed.” ACOG notes that for a woman already using compounded therapy, a blood estradiol level can help with adjusting the dose, and it gives 40 to 100 pg/mL as a generally reasonable range for symptom relief.
Safety: progesterone, the uterine lining and boxed warnings
- Progesterone with a uterus. Estrogen without a progestogen raises the risk of endometrial cancer in a woman with a uterus, and adding a progestogen lowers the risk of endometrial hyperplasia. BiEst contains estradiol, so the same rule applies.
- Estriol is included. In a Swedish case-control study, oral estriol at 1 to 2 mg a day for 5 years or more tripled the odds of endometrial cancer (odds ratio 3.0) and raised the odds of atypical hyperplasia more than eightfold; vaginal estriol did not raise the risk in that study. The National Academies found no studies on the endometrial safety of compounded estrogens and recommends boxed warnings on compounded estrogen prescriptions, estriol included.
- Boxed warnings are changing. On November 10, 2025, FDA asked makers of menopausal hormone therapy to remove cardiovascular, breast cancer and probable dementia language from their boxed warnings, keeping the endometrial cancer warning for systemic estrogen-alone products. As of October 3, 2026, Divigel’s label shows the new single warning, while EstroGel, Elestrin, Evamist, Climara and Vivelle-Dot still show the older four-part box.
- Who should not use estrogen. The current Divigel label lists undiagnosed abnormal genital bleeding, breast cancer or a history of it, estrogen-dependent cancers, blood clots in the legs or lungs or a history of them, liver disease, and inherited clotting disorders, along with past strokes and heart attacks.
- Dose accuracy. In a study of products from 13 compounding pharmacies cited by ACOG, most were within 10% of the label. Compounded estradiol creams ranged from 11% below to 1.4% above their label strength.
BiEst creams sold online without a prescription
Search for BiEst and you will find creams labeled “BiEST 2.5” and “BIEST 5.0” sold without a prescription. They are listed on the federal DailyMed database as over-the-counter products in the “unapproved drug other” category, with Drug Facts of 0.2% estriol and 0.05% estradiol (2.5 mg per gram at 80:20) or 0.4% and 0.1% (5 mg per gram). The labels claim relief from hot flashes, say “For external cosmetic use only,” and give no amount per application. Federal regulation treats any over-the-counter topical hormone product promoted for drug use as a new drug that needs an approved application.
A prescription BiEst is made by a licensed 503A pharmacy for one named patient on a clinician’s prescription. Estriol can be compounded because it has an official USP-NF monograph. Neither the prescription cream nor the over-the-counter creams are FDA-approved; the prescription comes with a clinician, a stated dose and progesterone when you need it.
What BiEst cream costs
These are prices from each provider’s own page, read October 3, 2026. Where a membership is required, it is part of the real monthly cost.
| Provider | BiEst price | Membership | What else the page states |
|---|---|---|---|
| Winona | From $89/mo for its 50/50 estrogen body cream | None shown | Dose and plan length behind the from-price not stated |
| Hone Health | $80/mo for the medication | $25 Basic or $155 Premium a month; the page does not say which is required | A $65 biomarker test to start |
| Healthspan | $64/mo at the member rate | Required, from $99 a month | Total not stated on the page |
| AgeMD | $249/mo program | None separate | Includes labs and clinician consults every 3 months; $199 intake |
| Amie | $149.97 every 3 months for an 80/20 cream | None shown | Strength and amount not compared here |
| PepScribe | $139/mo on the 3-month plan: $417 every 3 months, with $50 off every order ($367) | None | Covers the medication, clinician care and shipping |
Applying BiEst cream
Follow your pharmacy label. Directions on BiEst prescriptions from PepScribe’s pharmacy typically read: apply 0.5 or 1 mL to the inner thigh, inner arm or abdomen, once or twice a day. Keep the routine the same each day, since absorption from a cream can vary with the base it is made in.
How to get BiEst through PepScribe
- Start the free online visit at /book/hrt and answer questions about your symptoms and health history.
- A licensed clinician reviews your answers and, where indicated, your labs, and decides with you whether BiEst or another estrogen fits, paired with progesterone if you have a uterus.
- If BiEst is prescribed, it is compounded in the USA by a licensed 503A pharmacy and shipped to you, and your clinician adjusts the ratio or dose over time.
Plan details are on the BiEst page. For the progesterone side of a plan, see progesterone dosing in HRT, and for the broader safety picture, is HRT safe.
Frequently asked questions
What is BiEst cream?
A compounded cream that blends estriol and estradiol, usually 80:20 or 50:50, prescribed for symptoms of menopause. It is made by a pharmacy for one patient and is not FDA-approved.
How much estradiol is in BiEst 80/20?
Twenty percent of the labeled strength. A 2.5 mg per gram 80:20 cream holds 0.5 mg of estradiol and 2.0 mg of estriol per gram; at 5 mg per gram it holds 1.0 mg of estradiol.
What is the difference between BiEst 80/20 and 50/50?
The share of estradiol. At the same labeled strength, 50:50 carries 2.5 times the estradiol of 80:20.
Is BiEst safer than estradiol?
FDA says it has no evidence that drugs containing estriol are safer forms of estrogen. BiEst still contains estradiol, and oral estriol has been linked to endometrial cancer with long use, so a woman with a uterus uses BiEst with progesterone.
Do I need progesterone with BiEst?
If you have a uterus, yes. Estrogen without a progestogen raises the risk of endometrial cancer, and that includes the estradiol in BiEst.
Is BiEst FDA-approved?
No. There are no FDA-approved drugs containing estriol, and BiEst is available only as a compounded medicine prepared by a pharmacy for one patient.
Can I switch from BiEst to an estradiol patch?
Yes, with your clinician, though the milligrams do not convert directly. In the only head-to-head trial, 80:20 BiEst at 2.0 to 2.5 mg gave a fraction of the estradiol exposure of a 0.05 mg patch, so the new dose is set from your symptoms.
Provider prices: each provider’s own page, read October 3, 2026 (Winona, Hone Health, Healthspan, AgeMD, Amie). PepScribe’s price: its booking page, read the same day. Prices change; check before you compare.
