Patches, gels, tablets: the types of HRT, explained plainly

Estrogen is the hormone doing the therapeutic work: it is what eases flashes, sweats, broken sleep and the rest. If you have a uterus, progesterone comes alongside it, for one specific reason: estrogen alone thickens the womb lining over time, and progesterone keeps that in check. After a hysterectomy, estrogen alone is the norm.

Some women are also offered testosterone, most often for libido that has not responded to standard HRT. The evidence there is genuine but narrower, and it is usually a specialist addition rather than a starting point.

Estrogen through the skin, as a patch, gel or spray, goes straight into the bloodstream. Estrogen as a tablet passes through the liver first, and that first pass is where the blood clot risk associated with older HRT lives. Transdermal estrogen is not associated with that clot risk, which is why it has become the default suggestion for many clinicians, and close to a firm preference for women with any clotting history, migraine or higher body weight.

Between patch, gel and spray, the differences are practical rather than medical. Patches are twice-weekly and steady but visible and occasionally itchy. Gels and sprays are daily, invisible and easy to adjust, but need a dry patch of skin and a minute of patience. Women swap between them freely until one fits their life.

Progesterone most often comes as a capsule taken at night, where its mild drowsiness is a feature rather than a bug, or built into a hormonal coil, which handles the womb-lining job for five years while also covering contraception in perimenopause.

In perimenopause, while your own cycle still exists underneath, HRT is usually given sequentially: estrogen every day, progesterone for part of each month, with a planned monthly bleed. It works with the cycle you still have rather than fighting it.

A year or more past your final period, the usual pattern is continuous combined: both hormones daily, no planned bleed. Moving from one pattern to the other is routine, and some spotting in the first months of a new pattern is common rather than alarming, though bleeding that persists deserves a check.

Two nearly identical words, one real distinction. Body-identical means regulated, pharmacy-standard prescriptions whose molecules match your own hormones: micronized progesterone and estradiol, the forms most modern US and UK prescribing uses. The reassuring modern safety data mostly describes exactly these.

Compounded bioidentical hormones are custom mixes from compounding pharmacies, often marketed with saliva testing and personalization language. They are unregulated, unstandardized and more expensive, and the professional societies in both countries advise against them, not because the molecules are exotic but because the products are uncontrolled. If a clinic leads with the word bioidentical and a price list, that is a signal to keep looking.