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.
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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
- Spray
- Vaginal cream
- Vaginal gel
- 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. Note, progesterone is also given to some people with endometriosis, even if they have had a hysterectomy.
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.
Sequential or cyclical progesterone
This is recommended for women whose last period was less than one year ago. This medication contains a variable amount of progesterone per cycle, for example you may only need to take progesterone on certain days of the month. This variable hormone supply means that you will have a period-like bleed either every month or every three months, depending on the medication you are prescribed.
Continuous progesterone
If it has been over a year since your last period, continuous progesterone may be recommended. This means the same dose of progesterone will be taken every day. You will not have periods on this medication, and you should speak to your doctor if you experience any unexplained vaginal bleeding. Progesterone can be supplied as a:
- Capsule
- Patch (only available as a combination HRT product)
- Hormonal coil also known as a hormonal Intrauterine Device (IUD) such as Mirena, Levosert or Benilexa
- Vaginal capsule (these can be used as HRT, but are unlicensed)
Your doctor will speak to you about the right time to change from cyclical to continuous HRT.
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. Some people find it easier to use one medication, rather than two separate products.
- Tablets
- Patches
Note: combination products can contain either cyclical or continuous progesterone, or both!
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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 is not authorised to 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 experience 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 inside your vagina (or to the wider genital area) and only works where it is applied. This means it can be prescribed safely for most people as it is not absorbed into the bloodstream. It is a great option for people with vaginal, vulval or urinary symptoms and can be used either alone or alongside systemic HRT.
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). Many doctors will initially recommend patches or gels (transdermal HRT) as they are not thought to come with this increased risk.
- 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: Bijuve, Kliovance, Femoston Conti, Premique low dose* and Indivina
Oestrogen alone
- Oestrogen-only HRT tablet brands include Elleste Solo, Progynova, Zumenon 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. Micronised progesterone (available as the brand utrogestan) is thought to be associated with lower risks of serious blood clots (including DVT and PE) and breast cancer when compared with synthetic forms of this hormone (including the brand Provera).
*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, Estradot, Estraderm MX. 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
- Portable: Some gels come in sachets, which are easy to carry with you
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.
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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 systemic (whole-body) HRT. Speak to your doctor if you are unsure which product you have been prescribed.
Sprays
HRT sprays work in a similar way to 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
- The spray dries quickly on your skin, and is not messy to apply
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.
Find out more about HRT sprays.
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
- Vaginal HRT can be used alongside systemic HRT
What should you be aware of when using vaginal HRT?
- Vaginal oestrogen 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, Vagirux and Imvaggis. Some of these come with an applicator, but some people find it easier to insert the tablet with their finger. 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 and gels
- Oestrogen creams 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
- 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
Hormonal coils – Mirena, Levosert and Benilexa
If you still have your womb, you need to take some form of progesterone alongside your oestrogen HRT. If used alone, oestrogen can cause abnormal thickening and increase the risk of cancer in the womb lining (endometrium). Taking progesterone alongside the oestrogen effectively removes this risk. The progesterone can come from a combined HRT patch or tablet, or be supplied by a hormonal intrauterine Device (IUD).
The IUD is a small plastic device that sits inside the womb and slowly releases progesterone into the surrounding tissues. Three different types of coil are currently recommended for use as part of HRT – Mirena, Levosert and Benilexa. They all release the same amount of progesterone into the womb. Mirena has been on the market for the longest, but Levosert and Benilexa have both been recommended for HRT in recent guidelines.
What are the benefits of using a hormonal coil?
- Contraception plus lighter periods: A hormonal intrauterine Device (IUD) is a reliable form of contraception with the added benefit that it tends to make periods lighter and less frequent. If you have a hormonal IUD in place, you can simply add an oestrogen-only patch, tablet, gel or spray to complete your HRT plan.
- Long-term use: Once inserted, your coil can be used for five years as part of your HRT.
- Fewer side effects: If you’ve found that other kinds of progesterone cause side effects, you might find that an IUD is easier to tolerate. The progesterone released by the IUD does still spread around the body, but to a much lesser extent compared with pills or patches.
What should you be aware of when using a hormonal coil?
- Be aware that your coil needs to be changed every five years if being used for HRT
- If used for contraception only, Mirena can be used for eight years and Benilexa and Levosert for six years each. If you are 45 or over when your IUD is inserted, it can last until you are 55.
- Be aware that coils can fall out (most commonly into the loo). For this reason, it’s important to check your threads regularly to ensure that it’s still in place.
- Some women can experience discomfort during the procedure to put a coil in place, or in the weeks following the procedure. Read Alice’s story.
- Like all medications and contraceptive options, coils come with certain side effects and risks. Speak to your doctor to find out whether an IUD would be right for you.
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 people 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.
- Benefits and risks of HRT
- Difference between bioidentical hormones and body identical hormones
- Hillard, T. et al (2017). Management of the Menopause. ed. London: British Menopause Society
- FSRH, Intrauterine Contraception
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