How to Start a Hormone Therapy (BHRT) Practice

Written by Empire Medical Training Editorial Team

Medically reviewed by Betsy Greenleaf, DO Board-Certified OB/GYN & Urogynecologist; Empire Director of Anti-Aging

Updated June 2026 ·11 min read

Adding bioidentical hormone replacement therapy (BHRT) to a practice is, for most clinicians, less about whether the medicine is sound and more about how to build the service correctly: who you will treat, how you will test and monitor them, where you will source compounded hormones, how you will document and consent, and how you will price it. This guide is written for providers evaluating that move. It is a practical orientation, not a protocol manual — the full clinical and procedural depth is taught in Empire's hands-on hormone pellet therapy course.

It sits within our broader Hormone Replacement Therapy resource center and the Empire Anti-Aging & Functional Medicine program. Nothing here is medical or legal advice; scope, compounding, and compliance rules vary by state, and you should verify your own requirements.

Why add BHRT to your practice

Patient demand for hormone optimization is broad and growing. Natural menopause can begin as early as 38, with the average around 50 to 52, and modern chronic stress strains sex-hormone production well before that — so the population reporting fatigue, low libido, mood changes, weight gain, and poor sleep is large and underserved. Men experience an analogous age-related decline in testosterone. These are exactly the patients who arrive frustrated after being told their labs are “normal,” and they are highly motivated to pay for a clinician who will actually work the problem.

Operationally, BHRT is attractive for three reasons. It is predominantly a cash-pay service line — pellets and specialty hormone labs are often not covered by insurance, which means you set your own pricing and avoid much of the reimbursement friction. It generates recurring visits by design, because pellets are re-dosed roughly every three to six months and patients need ongoing monitoring. And it fits many practice types: family and internal medicine, OB/GYN, urology, aesthetics and med-spa settings, functional and anti-aging medicine, and wellness practices can all layer it in without rebuilding their model.

Who can offer it

Any licensed clinician with prescriptive authority can prescribe bioidentical hormones — physicians (MD/DO), nurse practitioners, and physician assistants — subject to state scope of practice and any collaboration or supervision requirements. There is no single mandatory BHRT certificate; the gating factor is competence within the standard of care, not a credential.

The pellet insertion itself is a minor in-office procedure using a trocar, well within the skill range of clinicians across these professions once trained. What separates a provider who can offer BHRT confidently from one who cannot is rarely licensure — it is whether they have learned hormone physiology, lab interpretation, patient selection, contraindications, dosing logic, and the insertion technique. That is precisely the gap structured training closes.

Getting trained — the step that anchors everything

If there is one decision that determines how quickly and safely you launch, it is getting properly trained first. BHRT looks simple from the outside — order labs, place a pellet — but the judgment is where patients are helped or harmed: who is a candidate, who is absolutely not, how to read tests that “cannot be converted back and forth” between methodologies, how to dose conservatively and adjust, and how to handle the inflammatory reactions and rare complications that occur at the insertion site.

Empire's hormone pellet therapy training — developed and taught by Dr. Betsy Greenleaf, DO, the first board-certified female urogynecologist and Empire's Director of Anti-Aging — is built around exactly this. It is CME-accredited, hands-on, and it deliberately pairs the clinical science with the practical, operational steps of standing up the service line. For most providers it is the single fastest path from “interested” to actually treating patients. The course is described in detail below, and there is a direct enrollment link at the bottom of this guide.

The clinical foundation

You do not need to master the full protocol to evaluate whether BHRT fits your practice, but you should understand the four pillars the training develops in depth: testing, patient selection, delivery methods, and monitoring.

Testing and lab interpretation

A reasonable workup considers a CBC, CMP, lipids, inflammatory markers, and hormone levels. Methodology matters enormously: serum is widely available and often insurance-covered but is “a snapshot in time, like a finger-stick glucose”; saliva is considered a strong option for most hormones; and urine metabolites reveal how a patient metabolizes estrogen but require specialty labs. A critical caution Dr. Greenleaf stresses is that reference ranges differ between labs and results cannot be converted between methods — so practitioners must develop a consistent lab practice. We cover this in depth on hormone testing and lab panels.

Patient selection and delivery methods

Selection is as much about screening out as screening in. Pellets and hormones are contraindicated in hormone-sensitive cancers, a history of clots, stroke or heart disease, liver disease, and pregnancy or breastfeeding, among others — and the specific contraindications differ by hormone and by patient. Delivery options each carry trade-offs: pellets offer high bioavailability and convenience but inconsistent absorption and slow taper; creams, patches, and injections are more controllable and easier to adjust. Hormone pellet therapy is the most common entry point, but the right method depends on the patient.

Monitoring

The governing principle is “start low and go slow,” treating the patient and not just the labs — if symptoms are controlled and levels are safe, that is a good outcome even when a number sits at the low end. Labs are typically rechecked a few months after placement, and pellets re-dosed on roughly a three-to-six-month cycle. The exact dosing ranges, titration logic, validated symptom questionnaires, and the insertion technique itself are taught step by step in the course — this page intentionally stops short of protocol-grade detail.

Compounding and sourcing

Bioidentical pellets and creams are not stocked at retail pharmacies; they are compounded. Most providers source patient-specific prescriptions from a 503A compounding pharmacy, while 503B outsourcing facilities can supply office-stock under different regulatory conditions. The practical guidance from the training is consistent: obtain pellets from reputable, accredited compounding pharmacies, and set up accounts with more than one. Multiple accounts help you compare pricing and keep treating patients when a product is on back order.

Two realities shape sourcing. First, potency varies — pellet absorption is inconsistent from person to person, pharmacy to pharmacy, and even batch to batch, which is one reason monitoring matters. Second, keep extra pellets and trocars on hand; a dropped pellet mid-procedure should never end the visit. You should also set up accounts with lab companies (many will walk you through reading their reports at no charge) and supplement vendors if you plan to bundle those. Evaluating and onboarding these pharmacy and lab relationships is part of what the course walks providers through.

Workflow and compliance

A defensible BHRT workflow has a few non-negotiable parts. Informed consent is first: it should explain what a pellet is, where and how it is placed, and — importantly — that compounded hormone pellets are not approved or regulated by the FDA. That single disclosure protects both patient and practice and should never be skipped.

From there, build a repeatable loop: intake and baseline labs, candidacy screen against contraindications, consent, the in-office procedure with instruments set up in advance, and scheduled follow-up labs and re-dosing. Validated symptom questionnaires are worth adopting to track progress objectively — and they become especially important if you ever bill insurance, which sometimes requires documented low levels before approving coverage. Practicing within your state scope, documenting thoroughly, and staying current with continuing education are what keep the service line inside the standard of care as the field evolves.

The business case — honestly

The reason BHRT pencils out for so many practices is structural, not hype. It is cash-pay, so you control pricing and sidestep reimbursement friction. It is recurring, because the three-to-six-month pellet cadence and ongoing lab monitoring bring patients back several times a year rather than once. And it bundles naturally into memberships and packages — a “hormone club” model that can fold in visits, lab tests, and supplements into a single recurring price.

What we will not do is promise numbers. National membership models vary enormously, and actual revenue depends on your market, your pricing, patient volume, pellet and lab costs, and how well you retain patients — there are no guaranteed returns. The honest framing is that BHRT offers an attractive structure (cash-pay plus recurring cadence plus packageable services), and your execution determines the outcome. For a deeper look at the cost side, see hormone pellet therapy cost.

Your first steps

If you have decided to move, the sequence the training recommends is straightforward:

• Get trained in hormone physiology, lab interpretation, patient selection, dosing, and the insertion procedure — the foundation for everything else.
• Set up lab accounts and book consultations with lab companies to learn how to read their specific reports.
• Set up accounts with multiple compounding pharmacies (and supplement vendors if bundling), vetting each for accreditation and reliability.
• Build your consent, intake, and monitoring workflow, including validated questionnaires and a clear contraindication screen.
• Decide how you will offer services — one-off visits, packages, or a recurring membership — and price accordingly.

The first item makes the other four faster and safer, which is why nearly every provider who launches well starts with the course.

Get trained and launch with confidence

BHRT rewards providers who learn it properly: the clinical judgment, the procedure, and the operational setup are all teachable, and learning them together is far more efficient than assembling them piecemeal. Empire's hormone pellet therapy training is designed to take you from interested clinician to confident provider — clinically and operationally — in a single CME-accredited, hands-on program.