Hormone therapy (HT) can be a complicated business. Even once you’ve decided to try it, there are lots of choices still to make. One of the most important is how to take your HT. Should you use a tablet? A patch? Or something else? How do you choose which type of HT is best for you? Read on to find out more about the different types of HT and what your options are.
Discover your personalized treatment options
What is HT?
Hormone therapy (HT) is a treatment for perimenopause and menopause symptoms. It can also protect the health of your bones and heart and reduce your risk of diabetes. It comes in the form of pills, patches, creams, and gels among others. It has been consistently proven to be the most effective treatment for a range of perimenopause and menopause symptoms such as mood changes, hot flashes, painful sex, and bladder symptoms.
It’s important that you discuss any symptoms with your healthcare provider to be sure of your diagnosis before you consider HT treatment. Other medical issues can mimic perimenopause and menopause symptoms.
Likewise, HT may not be suitable for you because of your medical history or you may just prefer not to take it. That’s ok, HT isn’t for everyone – there are alternative, non-hormonal medications, and lifestyle change can help too. Your healthcare provider will help you make an informed decision.
HT, HRT, and MHT – what’s the difference?
Research and self-education can improve your menopause experience and speed up the process of finding the right treatment for you. Confusing terminology can get in the way of this! We want to clear things up if you have come across the terms HRT, HT, or MHT and you’re not sure what they mean. The truth is, there is little difference between these abbreviations.
- HRT stands for hormone replacement therapy. Many symptoms of menopause are caused by a dramatic reduction in levels of certain hormones such as estrogen. This name suggests that the medication works by replacing the hormones that are no longer produced by your body during menopause
- HT, or hormone therapy, is a term that is growing in popularity as the way to describe this type of treatment, as HT does not technically ‘replace’ hormones. It is more accurate to say that the hormones in HT safely and effectively treat symptoms caused by changes in your body during menopause
- MHT, or menopausal hormone therapy, is a more precise phrase than HT. Hormones are used in lots of different medical treatments, so MHT is used to specifically describe HT for menopause and is often preferred by research scientists for this reason. You may see this phrase used in scientific research papers
Which hormones do you need?
Before deciding how to take your HT, you and your healthcare provider will have to decide which hormones you need. Speaking to them to discuss your symptoms and specific needs is important.
Forms of estrogen
Perimenopause and menopause symptoms are generally caused by a decrease in estrogen levels or, in some cases, an erratic release of this hormone.
HT works by supplying your body with estrogen, which has been proven to be the most effective treatment for many menopause symptoms. You will usually need to use some kind of estrogen as part of your HT.
Estrogen can be supplied as:
- Tablet
- Patch
- Gel
- Spray
- Vaginal cream
- Vaginal ring
- Vaginal suppository
Forms of progesterone
If you still have your uterus – you haven’t had a hysterectomy – you will also need to take progesterone. This is because if estrogen is used alone, it can cause the lining of the uterus to thicken abnormally. This can even lead to endometrial cancer in some cases. Progesterone protects the endometrium from this unwanted side effect of estrogen. Progesterone is also given to some people because is sometimes helps with specific menopause symptoms like poor sleep. It is also given to people with endometriosis, even if they have had a hysterectomy.
If you have had your uterus removed – a hysterectomy – you no longer have any uterus lining and are not at risk of this side effect. If this is the case, you can safely take estrogen alone.
Sequential or cyclical progesterone
This is recommended for women whose last period was less than one year ago. This method involves only taking progesterone for 10-16 days per month. This variable hormone supply means that you will probably have a predictable period-like bleed depending on the medication you are prescribed.
Continuous progesterone
If it has been over a year since your last period, continuous progesterone is usually 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 healthcare provider if you experience any unexplained vaginal bleeding. Progesterone can be supplied as:
- Oral capsule
- Patch (only available as a combination HT product)
- Intrauterine device (hormonal IUD)
- Vaginal capsule (only if other routes of administration are not working well for you)
Your healthcare provider will speak to you about the right time to change from cyclical to continuous HT.
Combined estrogen and progesterone
If you need to take both estrogen and progesterone for HT, as many do, there are numerous products available that combine the two. The combination comes in oral form and as a patch. Some people find it easier to use one medication, rather than two separate products.
Combination products can contain either cyclical or continuous progesterone or both!
Discover your personalized treatment options
Testosterone
Testosterone is a relative newcomer to the HT scene. It is not FDA-approved for menopausal hormone therapy. Some menopause experts support its use for women who are suffering from low libido and already using a traditional HT treatment. Like other forms of HT, it can be provided as a patch, gel, or cream.
Read more about testosterone HT.
What different types of HT are there?
- Systemic HT. This is HT that is absorbed into the bloodstream and treats body-wide menopause symptoms
- Vaginal estrogen. This is HT applied inside your vagina (or to the wider genital area) and only works near where it is applied. This means it can be prescribed safely for most people as only a tiny amount is 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 HT
Tablets
The very first HT products were taken in the form of tablets, and they are still used.
What are the benefits of HT tablets?
Convenience
This is a familiar choice for many and can slot into your routine easily if you are already taking other pills.
Extensive study
HT tablets have the most extensive research studies for understanding the risks, benefits, and side effects.
No skin contact
Others may prefer tablets if they are unable to use products that 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 HT tablets?
Increased risk of blood clots
Tablets are becoming a less common choice for HT. While they are effective at treating symptoms of menopause, they can be associated with some added risk of blood clots and gallstones when compared to other types of HT (like patches and gels).
Many healthcare providers will initially recommend patches or gels (transdermal HT) 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. On the other hand, if you already take daily pills, then remembering when to replace your patch may also be a challenge.
What kinds of HT tablets are available?
Combination of estrogen and progesterone (combined HT)
*Starred products contain equine estrogens, which are produced from the urine of pregnant horses. Some women choose to avoid these products for ethical reasons.
Combined HT tablet brands include:
- Activella
- Angeliq
- Femhrt
- Prefest
- Prempro*
Estrogen alone
Estrogen-only HT tablets include:
- Premarin* – conjugated equine estrogens
- Estrace – estradiol
- Enjuvia – synthetic conjugated estrogens
- Menest – esterified estrogen
If you still have your uterus, you will need to take progesterone alongside these products to protect your uterus lining.
Progesterone alone
This is used when estrogen is being taken in another form. For example, someone using an estrogen pill, spray, or gel.
Micronized progesterone is available as a generic and the brand Prometrium. It is associated with lower risks of serious blood clots, including DVT and PE, and breast cancer when compared with synthetic forms of this hormone, for example the brand Provera.
Patches
Chances are that if you ask a healthcare provider which type of HT they recommend, they will tell you to try a patch first.
Patches work effectively to treat menopause symptoms and appear to have slightly lower risks of blood clots than tablets.
What are the benefits of using HT patches?
Reduced risk of blood clots compared to HT tablets
This is thought to be because of the way HT patches release estrogen directly into the body without going through the liver. This means that they avoid some of the metabolic processes thought to be responsible for the increased risk of blood clots with HT tablets.
Convenience
Many users find HT patches convenient. Each patch lasts for three to seven days depending on the brand, so you only need to change it once or twice per week. Many 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 HT. Side effects of estrogen include breast tenderness, cramps, bloating, indigestion, nausea, and headaches. 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 HT patches?
It’s not all good news though! Some 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 the medication. It can be difficult for those who experience skin irritation with patches, which affects more than 1 in 10 users of some types of HT patches.
Stickiness
Certain users may also struggle to get the patch to stick, for example, if they 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.
Privacy
Even though patches are designed to blend in with your skin, sometimes they are still visible depending on what you wear.
Read more about HT patches.
What kinds of HT patches are available?
A combination of estrogen and progesterone (combined HT)
- Climara Pro
- Combipatch
Estrogen alone
Estrogen-only HT patch brands include:
- Climara
- Estraderm
- Minivelle
- Vivelle and Vivelle Dot
If you still have your uterus, you will need to take progesterone alongside these products to protect your uterus lining.
Gels
HT gels contain estrogen 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 HT gels?
Lower risk of blood clots
Just like HT patches, HT gels come with a lower risk of blood clots when compared to HT tablets.
Flexible dosage
Gels are also popular because it is easy to adjust the dose of estrogen to control your symptoms.
Discover your personalized treatment options
What should you be aware of with gels?
Difficulty opening the packets
If your gel is not a pump but small packets, 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 HT gels are available?
Estrogen-only HT gel in the US is sold under the brand names:
- Divigel
- Elestrin
- Estrogel
If you still have your uterus, you will need to take progesterone alongside these products to protect the uterine lining.
Read more about the pros and cons estrogen gel.
Sprays
HT sprays work similarly to gels. An estrogen-containing liquid is sprayed onto the skin and then absorbed directly into the bloodstream. Each spray gives a measured amount of HT, allowing the dose to be easily adjusted.
What are the benefits of HT sprays?
Lower risk of blood clots
HT sprays also appear to carry a lower risk of blood clots when compared to HT tablets.
Easy to use
The spray dries quickly on your skin and is not messy to apply.
What kinds of HT sprays are available?
The only HT spray currently available is Evamist, which is an estrogen-only form of HT.
If you still have your uterus, you will need to take progesterone alongside Evamist to protect the uterine lining.
Vaginal HT
Menopause can affect your vulva, vagina, and urinary tract. Because estrogen helps support the health of the urinary tract, vulva, and vagina, the declining levels of hormones at menopause can cause unpleasant changes. Common symptoms are vulvar itching, vaginal burning, tightness, painful sex, increases in UTIs 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 HT – estrogens which are applied directly to the affected area.
What are the benefits of vaginal HT?
Low risk
This form of HT has lower safety concerns with respect to blood clots, heart disease, breast cancer, or uterine cancer. This is because the hormones used are not absorbed into the bloodstream in any significant amount. Oncologists are generally OK allowing women with current or previous breast cancer to use vaginal HT.
Variety of options to suit you
There are multiple different ways of using vaginal HT, and they all work equally well. Ultimately, it is your choice as to which you find easiest to use.
Vaginal HT can be used alongside systemic HT.
What should you be aware of when using vaginal HT?
Vaginal estrogen treats genital areas symptoms
Be aware that vaginal HT will only treat symptoms in the genital area. If you are seeking help for other symptoms of menopause (including hot flashes, night sweats, and mood changes), speak to your healthcare provider about systemic HT (the tablets, patches, gels, and sprays discussed above).
What kinds of vaginal HT are available?
Vaginal tablets and suppositories
These are inserted into the vagina, where they slowly dissolve and release estrogen. The name of the tablet is Vagifem. Vagifem comes with an applicator, but some people find it easier to insert the tablet with their fingers. In the US there is a vaginal suppository called Imvexxy. If you have severe vaginal changes, like tightening and pain, you may find a cream or gel easier to insert than a tablet or suppository.
Vaginal creams
Estrogen 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 Estrace Ogen and Premarin*.
*Starred products contain equine estrogens, which are produced from the urine of pregnant horses. Some women choose to avoid these products for ethical reasons.
Vaginal ring
If you would like a low-maintenance option, you may like to discuss the vaginal ring. This is a soft silicone ring that is inserted into the vagina, where it slowly releases estrogen into the surrounding tissues. It needs to be changed only once every three months. Available under the brand name Estring.
Hormonal intrauterine devices (IUDs)
If you still have your uterus, you need to take some form of progesterone alongside your estrogen HT. While this can come from a combined HT patch or tablet, the protective progesterone can also be supplied by a hormonal IUD, such as Mirena or Liletta.
This small plastic device sits inside the uterus and slowly releases progesterone into the surrounding tissues. This progesterone protects the uterine lining from the abnormal thickening sometimes caused by the estrogens used for HT if taken alone.
What are the benefits of using a hormonal IUD?
Contraception plus lighter periods
For those who are still perimenopausal, the IUD protects from an overgrowth of the uterine lining and is an extremely reliable form of contraception. It also has the added benefit that it tends to make periods lighter and less frequent.
If you have an IUD in place, you can therefore simply add an estrogen-only patch, tablet, gel, or spray to complete your HT plan.
What should you be aware of when using a hormonal IUD?
Be aware that hormonal IUDs such as Mirena or Liletta are not FDA-approved for endometrial protection in the US, but many healthcare providers are very comfortable using them ‘off-label’. However, it is approved for this use in the UK and recommended to be replaced every 5 years.
It is also important to note that, while there are several hormone-releasing IUDs on the market, the only ones that should be used for endometrial protection are the Mirena and Liletta IUDs.
Some can experience discomfort during the procedure to put an IUD in place, or in the weeks following the procedure. Read more about what it is like to have a Mirena IUD.
Final word
There are many different HT options available. Generally, the best option is one which provides good symptom relief with the lowest possible risk. For most women, this is an estrogen patch, gel, or spray. This should be taken with some form of progesterone if you still have your uterus.
The number of choices may seem overwhelming, but your healthcare provider 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 HT products and evidence base change quickly. Your healthcare provider or pharmacist will be able to give you the most up-to-date information.
Find out more about menopause on our blog or in our symptoms library.
- Cleveland Clinic, Hormone therapy for menopause symptoms
- ‘The 2022 Hormone Therapy Position Statement of The North American Menopause Society‘ Menopause 29, no. 7 (July 2022): 767–94
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