Injection
Estradiol Cypionate
Long-acting estradiol injection for menopause and perimenopause symptoms and for gender-affirming hormone therapy, given every one to two weeks. Prescribed and dosed by a licensed physician.
Starting at $139/mo
BioidenticalMenopauseHormone therapy
BIEST 20:80 Cream
RxPrescription onlyApplied to the skin · Once a day · 4 clicks, 2.5 mg · Bioidentical · Menopause · Hormone therapy
Starting at $79/mo
Topical cream blending estriol and estradiol (20:80) for menopausal symptoms. Apply daily to skin. Gentle absorption, adjustable dosing.
Choose your plan
Real prices from our pharmacy. Longer plans cost less per month and are billed up front. Pause or cancel anytime.
- Bioidentical estriol, estradiol blend
- Topical application, flexible dosing
- Quick absorption through skin
Every plan includes
- Personalized, physician-guided plan
- Monthly, 3-month and 6-month plans
- Dispensed by a US-licensed compounding pharmacy
- Unlimited protocol adjustments and messaging
- Ongoing support and check-ins
- Pause or cancel anytime
- Reviewed by our in-house physicians
- Physician-guided care
- Ongoing, expert support
- 100% online
- Free, discreet shipping
What is BIEST 20:80 cream?
(20% estriol, 80% estradiol)
BIEST cream combines estriol (the weaker estrogen) and estradiol (the bioidentical form your ovaries made) in a 20:80 ratio, applied directly to skin. Absorption is gradual and local, making dose adjustment simple. Choose this form if you prefer topical application without pills or injections.
- How it is taken
- Applied to the skin
- How often
- Once a day
- Dose range
- 4 clicks, 2.5 mg
- Form
- Bioidentical · Menopause · Hormone therapy
20:80
the estriol to estradiol ratio for gentle absorption
Apply 0.5-1 gram daily to clean skin. Your physician adjusts based on symptom response and blood work.
How it works,
week by week.
Day 1
A US-licensed physician reviews your menopausal symptoms, history, and risk factors to set your dose.
Weeks 1-2
Hot flashes and night sweats usually ease within the first two to four weeks.
Month 1-2
Sleep and mood stabilize as hormone levels rise. Your physician checks in and adjusts dose if needed.
Month 3
Check-in. Your physician reviews symptom relief, any side effects, and confirms your dose going forward.
Beyond
BIEST therapy is reviewed yearly: dose, benefits, risks, and whether to continue.
What you may notice,
and when.
Fewer hot flashes
the most dramatic change from estrogen therapy
Better sleep and mood
as night sweats settle and hormones stabilize
Bone protection
estrogen slows bone loss at menopause
Steadier energy
many patients report clearer, more stable daily rhythms
Individual results vary. Benefits reflect what Zepym Health members commonly report to their physician at check-ins; they are not the results of a clinical trial.
Safety first:
what to know before you start.
Important safety information and common side effects
BIEST is a prescription hormone combination with real benefits and real risks. Common effects include breast tenderness, bloating, nausea, headache, spotting, and injection-site reactions. Estrogen therapy increases risk of blood clots, stroke, gallbladder disease, and, with a uterus, requires progesterone to prevent endometrial cancer. Not prescribed with breast cancer, blood clots, unexplained vaginal bleeding, liver disease, or pregnancy. Smoking raises clot risk. Seek care for chest pain, shortness of breath, leg swelling, severe headache, or vision changes. Tell your physician about every medication.
The research behind
Biest.
Biest is a compounded mix of estriol and estradiol, usually in an 80:20 or 50:50 ratio. It is not FDA-approved, and no outcome trial has tested it; the evidence is pharmacology and a few small studies.
- Outcome trialsNo outcome trials
No randomized trial has tested Biest against heart, bone or cancer outcomes, or against symptom relief. The 2020 National Academies review judged the evidence for compounded bioidentical hormones insufficient, and found most marketing claims unsupported by well-controlled studies.
National Academies, The Clinical Utility of Compounded Bioidentical Hormone Therapy, 2020 - Blood levelsLess estrogen than a patch
In a Mayo Clinic randomized trial of 40 postmenopausal women over 16 days, Bi-est cream at the lower doses gave much lower estradiol exposure than a standard estradiol patch with micronized progesterone. The study measured blood levels only, not symptoms or safety.
Bioidentical compounded hormones: a pharmacokinetic evaluation in a randomized clinical trial, Maturitas 2013 - Estriol partLimited, mixed evidence
The same National Academies review found limited, mixed-quality evidence that estriol may help some menopausal symptoms, and insufficient evidence about its long-term safety.
National Academies, 2020
What the studies found
- No human trial has shown a clinical benefit of Biest itself; the 2020 National Academies review found the evidence insufficient (NASEM, 2020)
- The estradiol component alone has trial evidence for hot flashes, but that evidence is for estradiol products, not for this mix (MacLennan, Cochrane 2004)
- A vaginal estriol gel had a placebo-controlled trial with symptom and cytology outcomes, but that was a single estriol product, not Biest (NCT04574999)
- Mechanistic only: the idea that a fixed estrogen ratio mimics the body's own is unproven in people
Compounded Biest is not the product studied in any trial. The idea that the body needs a particular estrogen ratio is not tested in outcome studies. The known risks of estrogen apply to Biest as well.
What this does not say
- No outcome trial exists for Biest; the blood-level study says nothing about symptoms or safety.
- Compounded doses are not standardized, so the amount in each capsule or cream can vary.
- The trials of estrogen cited elsewhere on this page used other products.
The research
behind it.
Transdermal estrogen bypasses first-pass liver metabolism, lowering gallbladder and clot risk slightly compared to oral forms. Estriol's weaker action appeals to patients seeking a gentler profile.
Like all estrogen therapy, BIEST cream carries risk of clots, stroke, and gallbladder disease. Risk rises with age, smoking, and time since menopause. Your physician reviews your risk factors before prescribing.
Hormone therapy beyond hot flashes:
what the research showsBones, the heart, vaginal health and sexual desire: the trials, with their numbers and their limits.Read the researchHormone therapy and breast cancer risk:
what the trials foundEstrogen alone and with progestin, why the two differ, and how physicians weigh it.Read the research
what the research showsBones, the heart, vaginal health and sexual desire: the trials, with their numbers and their limits.Read the researchHormone therapy and breast cancer risk:
what the trials foundEstrogen alone and with progestin, why the two differ, and how physicians weigh it.Read the research
Getting started
takes a few minutes.
- 1
Connect with a physician
Answer a few questions online and a US-licensed physician reviews your health, history and goals to make sure treatment is right for you. 100% online. No in-person visit required.
- 2
Get your discreet shipment
If approved, your treatment is compounded by a US-licensed, LegitScript-certified pharmacy, inspected for quality, and shipped discreetly to your door.
- 3
Receive continuous support
Start with one goal, then keep building over time. Unlimited physician messaging, easy refills and dose adjustments, all from the Zepym Health app.
Frequently asked questions
Contact supportHow do I use BIEST (20:80) Cream?
Applied to the skin, once a day. The starting prescription is 1 mL (4 clicks, 2.5 mg) each time. Your physician sets your own dose and it is printed on your label.
Where do I apply it?
Inner forearm or inner thigh.
What strengths does BIEST (20:80) Cream come in?
The pharmacy carries 8: 2.5 mg/mL, 1.25 mg/mL, 2 mg/mL, 0.4 mg/mL, 0.2 mg/mL, 1 mg/mL, 0.625 mg/mL, 3 mg/mL. Your physician chooses which one you get.
How much arrives in each shipment?
1 tube at the starting strength, shipped to your door from a licensed US pharmacy.
How much cream should I apply?
Your physician sets the starting dose, usually 0.5-1 gram daily. Use a metered applicator or measuring guide. Apply to clean, dry skin (inner arm, abdomen, or thigh work well). Adjust only under your physician's guidance.
Is BIEST really bioidentical?
Yes. Estriol and estradiol are both bioidentical, meaning their chemical structure matches what your body made. BIEST is a compounded formula mixing these two in a specific ratio.
Do I need progesterone with BIEST?
If you have a uterus, yes. Estrogen thickens the uterine lining, and progesterone protects it. After hysterectomy, estrogen alone is safe.
Is BIEST better than estradiol alone?
Not necessarily. Both work. BIEST appeals to patients seeking a lower dose, a gentler profile, or a compounded approach.
BIEST cream educational content reviewed by our physician
Scott Nass, MD Doctor of Medicine, board-certified in Family Medicine
Charles R. Drew University and David Geffen School of Medicine at UCLA. Family Medicine residency at Ventura County Medical Center.
More options
in this area.
Capsule
7-Keto DHEA Capsules
7-Keto DHEA, a metabolite of DHEA that does not convert to testosterone or estrogen. Supports energy and metabolism without hormonal side effects.
30 capsules per month
Starting at $89/mo
Dissolving tablet
BIEST (20:80) 0.05 mg ODT
A low-dose bioidentical estrogen (20% estriol, 80% estradiol) in a tablet that dissolves in the mouth, for hot flashes, night sweats and other menopause symptoms. Prescribed and dosed by a licensed physician.
30 tablets per month
Starting at $99/mo
Dissolving tablet
BIEST (20:80) 0.1 mg ODT
A stronger dose of bioidentical estrogen (20% estriol, 80% estradiol) in a dissolving tablet, for menopause symptoms not controlled by the lower dose. Prescribed and dosed by a licensed physician.
30 tablets per month
Starting at $99/mo
References
- 1.The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 2022
- 2.Estrogen and progestogen use in postmenopausal women: 2015 perspective. Lancet, 2015
Prescription products require an online evaluation with a licensed medical professional who will determine if a prescription is appropriate. Products are compounded by a licensed pharmacy. The FDA has not reviewed or approved compounded products for any use for safety, efficacy, or quality. Compounded medications are not FDA-approved brand-name products.