Our guide to different types of HRT for menopause | Stella
HRT
13 mins

Different types of HRT – which is right for you?

byDr Lucy Wilkinson

HRT can be a complicated business. Even once you’ve made the decision to try it, there are lots of choices still to make. One of the most important is how to take your HRT. Should you use a tablet? A patch? Or something else? And how do you choose which type of HRT is best for you? Dr Lucy Wilkinson explains more about the different types of HRT and what your options are.

Which hormones do you need?

Before deciding how to take your HRT, you and your doctor will have to decide which hormones you need. It’s important to speak to them to discuss your symptoms and specific needs. Here are some tips on how to have that conversation with your doctor.

Forms of oestrogen

Menopause symptoms are generally caused by a decrease in oestrogen levels or, in the case of hot flushes, an erratic release of this hormone.
HRT works by replacing oestrogen and this has repeatedly been proven to be the most effective treatment for many menopause symptoms. You will need to use some kind of oestrogen as part of your HRT.

Oestrogen can be supplied as a:

  • Tablet
  • Patch
  • Gel
  • Cream
  • Spray
  • Vaginal ring
  • Pessary

Forms of progesterone

If you still have your womb (you haven’t had a hysterectomy), you will also need to take progesterone because if oestrogen is used alone, it can cause the lining of the womb (the endometrium) to thicken abnormally. This can even lead to endometrial cancer in some cases. Progesterone protects the endometrium from this unwanted side effect of oestrogen.  

If you have had your womb removed (a hysterectomy), you no longer have any womb lining and are not at risk of this side effect. If this is the case, you can safely take oestrogen on its own.

Progesterone can be supplied as a:

  • Tablet
  • Patch
  • Intrauterine system (Mirena coil)

Combined oestrogen and progesterone

If you need to take both oestrogen and progesterone for HRT, as many do, there are numerous products available which combine the two. These combined products can be either ‘sequential’ or ‘continuous’.

Sequential combined HRT

This is also sometimes known as ‘cyclical HRT’ and is recommended for women whose last period was less than one year ago. This medication contains daily oestrogen, with a variable amount of progesterone per cycle. This variable hormone supply means that you will have a period-like bleed either every month or every three months.

Continuous combined HRT

If it has been over a year since your last period, continuous combined HRT may be recommended. This contains both oestrogen and progesterone to be taken every day. You will not have periods on this medication.

Testosterone

Testosterone is a relative newcomer to the HRT scene. The UK’s National Institute for Clinical Excellence (NICE) currently only recommend using testosterone for reduced sexual desire, and only if standard HRT does not help. 

This is currently an off-label use in the UK, which means that although there is enough evidence for NICE to recommend the use of the medication, the manufacturer does not currently recommend it for this use. The same is true in the USA, as testosterone products are not currently approved for use in women by the FDA.

This is a common practice across many areas of medicine, from paediatrics to gynaecology. However, it means that testosterone is prescribed only with extra caution and usually by a doctor with a special interest in menopause (either a gynaecologist, a sexual health specialist or a specialist doctor).

Testosterone can be supplied as a gel or cream, with brand names including:

  • Tostran
  • Testogel
  • AndroFeme

We’re focusing mainly on oestrogen and progesterone-based HRT in this article, but you can find out more about testosterone HRT over on the BMS website.

What different types of HRT are there?

  • Systemic HRT. This is HRT that is absorbed into the bloodstream and your entire body, treating body-wide menopause symptoms
  • Vaginal oestrogen. This is HRT applied to your genital area and only works where it is applied

Tablets

The very first HRT products were taken in the form of tablets, and they are still used. 

What are the benefits of HRT tablets?

  • Convenience: This is a familiar choice for many, and can slot into your routine easily if you are already taking other pills
  • No skin contact: Others may prefer tablets if they are unable to use products which are applied to the skin – for example, if you struggle with a skin condition or are allergic to patches

What should you be aware of with HRT tablets?

  • Increased risk of blood clots: Tablets are becoming a less common choice for HRT. While they are effective at treating symptoms of menopause, they are associated with added risks when compared to other types of HRT (like patches and gels).

    For example, taking HRT in tablet form can increase your risk of serious blood clots including deep vein thrombosis (DVT) and pulmonary embolism (PE). We do not see this increased risk in women who take HRT as patches or gels, which is why many doctors will initially recommend this type of HRT.
  • Remembering to take it: The tablet format itself can also be a problem for some women. If you are the kind of person who struggles to remember medicines or doesn’t want the hassle every day, a patch might be a better option.

What kinds of HRT tablets are available?

A combination of oestrogen and progesterone (combined HRT)

  • Sequential combined HRT tablet brands include: Elleste Duet, Femoston and Prempak C* 
  • Continuous combined HRT tablet brands include: Kliovance, Femoston Conti, Premique low dose*, Indivina and Angeliq

Oestrogen alone

  • Oestrogen-only HRT tablet brands include Elleste Solo and Premarin*. If you still have your womb, you will need to take progesterone alongside these products to protect the womb lining

Progesterone alone

  • This is used when oestrogen is being taken in another form. For example, a woman using an oestrogen spray or gel may choose to take the protective progesterone as a tablet. Brands available include Utrogestan (also known as ‘micronised progesterone’).

*Starred products contain equine oestrogens, which are produced from the urine of pregnant horses. Some women choose to avoid these products for ethical reasons.

Patches

Chances are that if you ask a doctor which type of HRT they recommend, they will tell you to try a patch first.

Patches work effectively to treat menopause symptoms, but come without some of the more concerning risks that we see with tablets.

What are the benefits of using HRT patches?

  • Reduced risk of blood clots. This is thought to be because of the way HRT patches release hormones into the body. As oestrogen and progesterone are absorbed directly into the bloodstream, they do not need to be absorbed from the digestive tract or processed by the liver. This means that they avoid some of the metabolic processes thought to be responsible for the increased risk of blood clots with HRT tablets.
  • Convenience. Many users find HRT patches convenient. Each patch lasts for three to four days, so you only need to change it twice per week. Many women build patch changes into their routines on certain days – for example, every Sunday and Wednesday.
  • Fewer side effects. Patches also tend to produce fewer side effects than oral HRT. Side effects of oestrogen include breast tenderness, cramps, bloating, indigestion, nausea and headaches. Side effects of progesterone include premenstrual-type symptoms, breast tenderness, fluid retention and mood swings among others. While some women do still experience these side effects with patches, they are thought to be lessened due to the direct absorption of the hormones into the bloodstream.

What should you be aware of with HRT patches?

It’s not all good news though! Some women find that patches just aren’t the best fit for them. 

  • Skin irritation: Patches can be especially tricky for those with skin problems (which can affect both patch placement and absorption of medication) or who experience skin irritation with patches (which affects more than 1 in 10 users of some types of HRT patch)
  • Stickiness: Certain users may also struggle to get the patch to stick (for example, if you tend to sweat a lot or wear tight clothing). Although they are designed to withstand baths, showers, swimming and other sports, this may be a problem for some. It can also be difficult to get the adhesive off your skin

What kinds of HRT patches are available?

A combination of oestrogen and progesterone (combined HRT)

  • Sequential combined HRT patches include: Evorel sequi, FemSeven Sequi
  • Continuous combined HRT patches include: Evorel conti, FemSeven Conti

Oestrogen alone

  • Oestrogen-only HRT patch brands include: Evorel, Elleste Solo Mx, Estradot. If you still have your womb, you will need to take progesterone alongside these products to protect the womb lining.

Gels

HRT gels are becoming increasingly popular. These products contain oestrogen which is spread on the skin and then absorbed directly into the bloodstream. Gels are usually applied to the outer arm or inner thigh. It then needs to be allowed to dry for five minutes before dressing, and should be left for at least an hour before washing or applying any other skincare products.

What are the benefits of using HRT gels?

  • Lower risk of blood clots: Just like HRT patches, HRT gels come with a much lower risk of blood clots when compared to HRT tablets 
  • Flexible dosage: Gels are also popular because it is easy to adjust the dose of oestrogen to control your symptoms

HRT gels come in a pump pack, and each pump is one ‘dose’. For example, one pump of Oestrogel contains 25mcg of oestrogen. Most women begin by taking one to two doses, but your doctor may recommend increasing this if needed.

What should you be aware of with gels?

  • Difficulty opening the sachets. If your gel is not a pump but tiny sachets, they can be difficult to open, especially if you have joint pain or arthritis
  • Drying time. You need to wait a few minutes for the gel to be fully absorbed into the skin, which can be chilly in winter or may be inconvenient for your routine

What kinds of HRT gels are available?

Oestrogen-only HRT gel brands include Sandrena and Oestrogel. If you still have your womb, you will need to take progesterone alongside these products to protect the womb lining.

Be aware that HRT gels are also used for vaginal HRT, although these are different products and not interchangeable with the gels used for general HRT. Speak to your doctor if you are unsure which product to use.

Sprays

HRT sprays work in the same way as gels. An oestrogen-containing liquid is sprayed onto the skin and then absorbed directly into the bloodstream. Each spray gives a measured amount of HRT, allowing the dose to be easily adjusted.

What are the benefits of HRT sprays?

  • Lower risk of blood clots: HRT sprays are also lower risk when compared to HRT tablets, with no excess risk of blood clots

What kinds of HRT sprays are available?

The only HRT spray currently on the market is Lenzetto, which is an oestrogen-only form of HRT. 

If you still have your womb, you will need to take progesterone alongside Lenzetto to protect the womb lining.

Vaginal HRT

Menopause can affect your genitals and urinary tract. As the tissues in this area are kept healthy by the presence of oestrogen, the declining levels of hormone at menopause cause unpleasant changes. Common symptoms are itching, burning, tightness, painful sex and needing to pee more frequently. This is known as the genitourinary syndrome of menopause (GSM), although you may also see it referred to as vaginal atrophy or atrophic vaginitis.  

These symptoms can be treated effectively with vaginal HRT – oestrogens which are applied directly to the affected area. 

What are the benefits of vaginal HRT?

  • Low risk: This form of HRT is the safest currently in use. This is because the hormones used are not absorbed into the bloodstream in any significant amount, meaning that there is no associated risk of blood clots, stroke, breast cancer or endometrial cancer
  • Variety of options to suit you.  There are multiple different ways of using vaginal HRT, and they all work equally well. Ultimately, it is your choice as to which you find easiest to use

What should you be aware of when using vaginal HRT?

  • Treats limited symptoms. Be aware that vaginal HRT will only treat symptoms in the genital area. If you are seeking help for other symptoms of menopause (including hot flushes, night sweats and mood changes), speak to your doctor about systemic HRT (the tablets, patches, gels and sprays discussed above).

What kinds of vaginal HRT are available?

Vaginal tablets and pessaries

  • These are inserted into the vagina, where they slowly dissolve and release oestrogen. Brand names include Vagifem and Imvaggis. If you have severe vaginal changes (like tightening and pain), you may find a cream or gel easier to insert than a tablet or pessary

Vaginal creams

  •  These can be used inside the vagina and applied directly to any external tissues which are affected (including the vulva, labia, clitoris and perineum). Brand names include Ovestin and Gynest

Vaginal gel

  •  Just like creams, gels can be used both internally and externally. Be aware that this is a different product from the oestrogen gels used for systemic HRT! If you aren’t sure which product to use, speak to your doctor. Brand names for vaginal HRT gel include Blissel

Vaginal ring

  •  If you would like a low-maintenance option, you may like to discuss the vaginal ring. This is a soft plastic ring which is inserted into the vagina, where it slowly releases oestrogen into the surrounding tissues. It needs changing only once every three months. Available under the brand name Estring

Intrauterine systems (Mirena coil)

If you still have your womb, you need to take some form of progesterone alongside your oestrogen HRT. While this can come from a combined HRT patch or tablet, the protective progesterone can also be supplied by a Mirena coil. 

This small plastic device sits inside the womb and slowly releases progesterone into the surrounding tissues. This progesterone protects the womb lining from the abnormal thickening sometimes caused by the oestrogens used for HRT if taken alone.

What are the benefits of using the Mirena coil?

  • Contraception plus lighter periods: This is very much welcomed by the many women who use the Mirena as a reliable form of contraception (with the added benefit that it tends to make periods lighter and less frequent).

If you have a Mirena in place, you can therefore simply add an oestrogen-only patch, tablet, gel or spray to complete your HRT plan.

What should you be aware of when using the Mirena coil?

Be aware that the Mirena needs to be changed every 4 years if being used for HRT (rather than the usual 5 years if used for contraception only).

It is also important to note that, while there are several hormone-releasing coils on the market, the only one currently licensed for use in HRT is the Mirena.

  • Some women can experience discomfort during the procedure to put a Mirena coil in place, or in the weeks following the procedure. Read Alice’s story.

Final word

There are many different HRT options available. Generally, the best option is one which provides a balance of good symptom relief with the lowest possible risk. For most women this is an oestrogen patch, gel or spray. This should be taken with some form of progesterone if you still have your womb.

The amount of choice may seem overwhelming, but your doctor will be able to guide you on the best options for you and your lifestyle.

Please note all information in this article was correct at the time of publication. However, the availability of HRT products and evidence base change quickly. Your doctor or pharmacist will be able to give you the most up-to-date information.