Types of HRT — what is actually available
Patches, gels, pills, implants, creams, pessaries. Body-identical progesterone, synthetic progestins, the Mirena coil. Combined or sequential. The choice matters — and almost nobody explains it. Rose covers every formulation, what makes each different, and which questions to ask.
Rose
"When my doctor first mentioned HRT I thought it was one thing. I had no idea there were different types of estrogen, different ways to deliver it, different progestogens with completely different safety profiles. The difference between body-identical micronised progesterone and the synthetic progestin used in the 2002 WHI study is enormous — and almost no one explains it. This page is what I wish I had read before my first appointment."
Key takeaways
✓HRT is not one thing — it is a combination of estrogen type, delivery method, and progestogen type, each with different safety profiles
✓Transdermal estrogen (patch or gel) has a lower clot and stroke risk than oral tablets — this is not a small difference
✓Body-identical micronised progesterone (Utrogestan) has the best safety profile of all progestogens — the breast cancer signal in the WHI study came from a synthetic progestin, not this
✓The choice of progestogen matters as much as the choice of estrogen — ask specifically for micronised progesterone
✓Local vaginal estrogen is not systemic HRT — it treats vaginal and urinary symptoms only but is safe even for most breast cancer survivors
✓If you still have a uterus, you need a progestogen alongside estrogen — estrogen alone causes endometrial cancer risk without it
✓Women who have had a hysterectomy can take estrogen alone — no progestogen needed
Part 1 — Estrogen: the delivery methods
Estrogen is the primary active component of HRT — the hormone that addresses hot flashes, sleep, bone density, cardiovascular protection, vaginal health, and cognition. The form and route of delivery matters significantly for safety and tolerability.
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Patches
Transdermal — changed twice weekly
Strong evidence
A small adhesive patch applied to the lower abdomen, buttock, or thigh and changed every 3-4 days. The most commonly prescribed transdermal estrogen in the UK. Estrogen absorbs through the skin directly into the bloodstream — bypassing the liver entirely.
Advantages
✓ No first-pass liver metabolism — lower clot risk than oral estrogen
✓ Consistent steady delivery — fewer hormone peaks and troughs than oral
✓ Available in multiple strengths for easy dose adjustment
✓ Twice-weekly application — easy routine
✓ Suitable for women with migraines, liver conditions, or clot risk
Considerations
• Adhesion can be unreliable — some women have issues with patches falling off
• Skin irritation at application site in some women
• Visible when wearing swimwear
Rose on this
"The patch is what most menopause specialists start women on in the UK. The transdermal route is the modern standard — the liver bypass is not a small thing."
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Gel
Transdermal — applied daily
Strong evidence
A clear gel applied to the inner arm, thigh, or shoulder once daily and allowed to dry. Same transdermal mechanism as patches — absorbed through the skin, bypassing the liver. More flexible dosing than patches as the number of pumps can be adjusted precisely.
Advantages
✓ Most flexible dosing — adjust by half a pump increment
✓ No adhesion issues — invisible once dry
✓ No skin irritation at application site
✓ Transdermal — same liver bypass benefit as patches
✓ Easy to titrate during perimenopause when needs are fluctuating
Considerations
• Daily application required — some women prefer twice-weekly patches
• Transfer risk — must dry completely before contact with others
• Measuring dose requires care — pump variations exist between brands
Rose on this
"Gel suits women who want maximum flexibility. If you are still in perimenopause and your estrogen needs are shifting month to month, gel lets you adjust without changing prescription."
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Tablets (oral estrogen)
Oral — taken daily
Strong evidence
The original form of HRT — estrogen tablet taken daily. Effective but metabolised through the liver on first pass, which activates clotting factors. Still widely prescribed but generally no longer the preferred formulation for new starts.
Advantages
✓ Familiar format — easy for women used to taking daily medication
✓ Well-studied — decades of efficacy data
✓ Lower cost than some other formulations
Considerations
• First-pass liver metabolism — increases clotting factors and VTE risk compared to transdermal
• Studies show 2-3x higher risk of deep vein thrombosis vs transdermal at equivalent doses
• More variable blood levels — peaks and troughs throughout the day
• Not recommended for women with migraine with aura, prior VTE, or liver conditions
Rose on this
"The evidence is now clear that transdermal estrogen is safer than oral for most women. If you are on oral tablets and have no reason you cannot switch, it is worth asking about transdermal."
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Implants (pellets)
Subcutaneous — every 4-8 months
Moderate evidence
A small pellet of crystalline estrogen (and sometimes testosterone) inserted under the skin of the buttock under local anaesthetic. Releases hormones steadily over 4-8 months. Not widely available — mainly through private clinics.
Advantages
✓ No daily or twice-weekly application
✓ Very consistent hormone delivery
✓ Often combined with testosterone in one implant
✓ Preferred by some women who struggle with compliance
Considerations
• Minor surgical procedure every few months
• Cannot adjust or reverse once inserted
• Not available on NHS — private only in most cases
• Less research than patch or gel
Rose on this
"Implants suit women who want to set and forget. The inability to quickly adjust is the main limitation — if your needs change, you are waiting for the implant to run down."
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Vaginal estrogen
Local — cream, ring, or pessary
Strong evidence
Estrogen applied or inserted directly into the vagina. Treats Genitourinary Syndrome of Menopause (GSM) — vaginal dryness, discomfort, urinary symptoms. Minimal systemic absorption at standard doses. Not a substitute for systemic HRT — it addresses local symptoms only.
Advantages
✓ Minimal systemic absorption at standard doses — considered safe even for breast cancer survivors in most guidelines
✓ Highly effective for vaginal dryness, pain during sex, and urinary urgency
✓ Can be used alongside systemic HRT or as a standalone treatment
✓ Available in multiple formats — cream, ring, pessary
Considerations
• Local effect only — does not address hot flashes, sleep, mood, bone, or cognition
• Must be used continuously — symptoms return if stopped
• Some women find application messy or inconvenient
Rose on this
"Vaginal estrogen is one of the most undertreated menopause interventions. It is not HRT in the systemic sense — it is local tissue maintenance. Every postmenopausal woman experiencing any vaginal discomfort should know it exists."
Part 2 — Progestogens: body-identical vs synthetic
Why the progestogen choice matters as much as the estrogen choice
If you have a uterus, you need a progestogen alongside estrogen. Estrogen alone causes the uterine lining to thicken unchecked — which over time increases endometrial cancer risk. The progestogen counteracts this.
But not all progestogens are equal. The 2002 WHI study that caused millions of women to stop HRT used medroxyprogesterone acetate (MPA) — a synthetic progestin with a different molecular structure from natural progesterone. It is now widely understood that MPA carries risks that body-identical micronised progesterone does not.
Asking specifically for micronised progesterone — rather than accepting whatever combined tablet comes off the prescription pad — is one of the most important things you can do when starting HRT.
Micronised progesterone (Utrogestan)
Body-identical
Chemically identical to the progesterone your body produces. Derived from yams, but the molecule is indistinguishable from human progesterone. The current preferred progestogen in menopause guidelines.
Advantages
✓ Best safety profile of all progestogens — particularly for breast cancer risk
✓ Does not increase VTE (clotting) risk at standard doses
✓ Has calming, sleep-supporting effects — progesterone is naturally sedative
✓ Body-identical — the molecule your receptors were designed for
✓ Endorsed by BMS and most menopause specialists as first-line choice
Considerations
• Oral form is metabolised through the liver — though at lower doses than older progestogens
• Some women experience drowsiness (can be an advantage taken at bedtime)
• Vaginal micronised progesterone is the purest form but less convenient
Levonorgestrel IUS (Mirena)
Synthetic progestin — local
The hormonal coil releases levonorgestrel locally into the uterus. Very low systemic absorption — provides endometrial protection for HRT without significant systemic progestogen effects. Lasts 5 years.
Advantages
✓ Very low systemic absorption — minimal progestogen side effects
✓ Provides contraception simultaneously
✓ Reduces or stops periods — useful for perimenopausal flooding
✓ 5-year duration — no daily medication
Considerations
• Insertion procedure — discomfort varies
• Irregular spotting common in first 3-6 months
• Does not replace systemic HRT — still needs estrogen for hot flashes and bone protection
Medroxyprogesterone acetate (MPA)
Synthetic progestin
The synthetic progestin used in the 2002 WHI study that generated widespread HRT fear. Still in some combined HRT preparations. The evidence suggests it has a less favourable safety profile than micronised progesterone.
Advantages
✓ Well-studied — decades of data
✓ Effective at endometrial protection
✓ Available in combined HRT pills for convenience
Considerations
• The progestin implicated in the WHI breast cancer signal
• Higher cardiovascular risk than micronised progesterone in some analyses
• Does not have the sleep benefits of body-identical progesterone
• Generally no longer first-line in modern menopause practice
Norethisterone / Norgestimate
Synthetic progestin
Other synthetic progestins used in some combined HRT and contraceptive preparations. Variable profiles — norethisterone has some androgenic activity which affects mood and libido differently than micronised progesterone.
Advantages
✓ Available in convenient combined preparations
✓ Effective endometrial protection
Considerations
• Androgenic side effects in some women — acne, mood changes, reduced libido
• Higher VTE risk than micronised progesterone
• Generally not preferred over micronised progesterone when choice is available
Part 3 — Sequential vs continuous regimens
Sequential (cyclical)
Estrogen daily + progestogen for 12-14 days per month
Mimics the natural cycle. You will have a monthly bleed during or after the progestogen phase. Recommended in perimenopause when periods are still occurring.
Best for: perimenopause, women who prefer a monthly bleed pattern
Continuous combined
Estrogen and progestogen both daily, continuously
No monthly bleed. Requires 12 months without a period before starting — otherwise irregular spotting is common. Simpler daily routine for postmenopausal women.
Best for: postmenopause (12+ months after last period)
The prescription conversation — specific questions that matter
1. "Can I have transdermal estrogen — a patch or gel — rather than oral tablets?"
2. "For the progestogen, can I have micronised progesterone (Utrogestan) specifically?"
3. "I still have a uterus — what progestogen protection will I have?"
4. "What dose are you starting me on and when should we review it?"
5. "Can we also discuss my testosterone level?"
Rose on this
"The difference between the HRT that scared women for twenty years and the HRT available today is largely a difference in formulation. Transdermal estrogen. Body-identical progesterone. These are not the same drugs that were in the 2002 study. Knowing that — being able to name what you want and why — changes the appointment."
From Rose
"You do not have to accept whatever comes off the prescription pad first. You can ask for transdermal. You can ask for micronised progesterone. You can ask about testosterone. An informed patient gets better treatment — not because doctors are withholding, but because the consultation is short and the default is familiar. Know what you want before you walk in."
What we do not know yet
?The optimal duration of HRT — current guidelines say as long as benefits outweigh risks, but long-term data beyond 20 years is limited
?Whether micronised progesterone delivered vaginally (the purest systemic-absorption-free route) offers meaningful additional safety benefits over oral micronised progesterone
?The optimal timing of HRT initiation for cardiovascular and cognitive protection — the "timing hypothesis" suggests earlier initiation is more beneficial but the data is not yet definitive
Written by
Rose
Navigating perimenopause · Researcher · Founded rosemyfriend.com
Research basis
PubMed · Cochrane reviews · NICE guidelines · British Menopause Society · The Menopause Society
Read methodology →
Rose provides evidence-graded educational information — not medical advice. Always discuss health decisions with a qualified healthcare provider.
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