HRT Types — Estrogen, Progesterone, and Delivery Methods

Menopause hormone therapy (HRT) is not a single product but a family of treatments that differ by hormone type, delivery route and regimen. The right choice depends on several things: whether you still have your uterus, which symptoms bother you most, your health risks and your preferences. The bottom line: there is no one-size-fits-all formula, but there is almost certainly an option that suits you, and the decision belongs to you and your clinician together, not to hearsay.

Why one regimen suits one woman and not another:

Two women can be the same age, at the same stage, with the same symptoms, and still end up on different prescriptions. That is not confusion on the prescriber's part. It reflects how much individual variation sits underneath the same label.

The same dose does not produce the same levels in everyone. How much is absorbed, how quickly the liver clears it, and how sensitive your own tissues are to it all vary. Which symptom bothers you most matters too: a regimen chosen for night sweats may not be the one chosen for vaginal dryness, and the two are handled differently. So does what you can tolerate. A form that suits one woman's skin, routine and memory may be a daily nuisance to another.

It also helps to know which parts of this are settled and which are still argued about. That oestrogen relieves the symptoms listed above, and that a woman with a uterus needs a progestogen alongside it, is not in dispute. What is still debated is how much weight to give small differences between products, and how to match a particular progestogen to a particular woman. Those are judgement calls, and good clinicians make them with you rather than for you.

How does HRT work?

Hormone therapy replaces the hormones that fall at menopause, to relieve symptoms such as hot flashes, night sweats, vaginal dryness and sleep disruption. Oestrogen is the component that treats most symptoms. Women who still have a uterus must also take a progestogen, which protects the uterine lining and prevents endometrial cancer, while women without a uterus can use oestrogen alone.

Which oestrogen formulation is right for you?

• Oral, as tablets: convenient and well studied, but with a slightly higher risk of blood clots; standard doses are 1-2 mg oestradiol or 0.625 mg conjugated equine oestrogen
• Transdermal, via patch, gel or spray: oestrogen is absorbed through the skin and bypasses first-pass liver metabolism, which means a lower clot risk; it is preferred for women with migraine, a body mass index over 30, or risk factors for clots
• Vaginal, via cream, tablet or ring: minimal systemic absorption, used for the genitourinary syndrome of menopause, not for hot flashes

We do not choose between oral and transdermal on effectiveness but on risk profile and tolerance. Vaginal oestrogen should not be confused with the systemic forms: it works locally and is not meant to treat hot flashes.

What "bioidentical" does and does not mean:

The word bioidentical is used freely in advertising, and it is worth knowing exactly what it describes. It means the hormone molecule is the same as the one the body makes. It is a statement about structure, not about safety, quality or strength.

That distinction matters, because the word is often read as a promise that a product is gentler or more natural. Structure alone does not tell you how a product was tested, how reliable its absorption is, or whether what is in the container matches what is on the label. So the useful question is not whether a product is bioidentical, but whether the one in front of you has been tested and regulated.

A short set of questions cuts through the marketing:

• Is this the same product that has been tested, or a version made up for me?
• Is it regulated as a medicine, or sold as a supplement?
• What is the dose, and how was it decided?
• Has it been used in women in my situation?

You are entitled to ask these before agreeing to anything, and a prescriber who welcomes the questions is a good sign. None of this means that the familiar products are the only sensible choice, or that the word bioidentical is meaningless. It means the word alone is not enough to make a decision on.

Progestogen, for women with a uterus:

• Micronised progesterone (Prometrium, Utrogestan) is bioidentical and often has a better profile for sleep and mood; it is taken at night
• Synthetic progestins (MPA, norethisterone, dydrogesterone) are effective but may carry more metabolic and mood side effects
• The Mirena coil (levonorgestrel) releases progestogen locally, directly into the uterus, and suits women who cannot tolerate systemic progestogens

This component is not optional for women with a uterus: without it, oestrogen stimulates the uterine lining unchecked and raises the risk of endometrial cancer. If you have had a hysterectomy, progestogen is no longer needed.

How the progestogen side gets chosen:

For a woman with a uterus, the progestogen is not an optional extra, so choosing it well is worth some attention. The options already described have different strengths and different drawbacks, and the right one depends on what else is going on.

The bioidentical form is often chosen when sleep and mood are part of the picture, and because it is taken at night it can double as part of a bedtime routine. The synthetic progestins are effective and well established, and they suit women who do not get on with the bioidentical one. The intrauterine option releases its hormone locally, which makes it a useful answer for women who cannot tolerate a systemic progestogen at all.

If you still have periods, the regimen will be a sequential one, and the progestogen will shape what those bleeds are like. If you are past your final period and on a continuous combined regimen, the usual aim is no bleeding at all. Either way, ask what pattern to expect on the regimen you are given, and ask which changes would need to be looked at rather than waited out. Knowing that in advance saves a great deal of worry later.

Regimens:

• A sequential regimen means daily oestrogen plus progestogen for 12-14 days each month, and is used by women who still have periods
• A continuous combined regimen means daily oestrogen and progestogen, is used by postmenopausal women and usually leads to no bleeding
• Tibolone is a synthetic steroid with oestrogenic, progestogenic and androgenic activity, used in some countries

Moving from one regimen to another is common: women who complete the transition often switch from sequential to continuous combined. The aim is to find the schedule that controls symptoms with the least disruption.

Settling in, and what to do about side effects:

Starting hormone therapy is not like starting an antibiotic, where the effect is quick and the course is fixed. It is more like tuning an instrument. Some effects ease as your body adjusts. Others are a signal that the route or the progestogen should change rather than that hormone therapy is wrong for you.

The way to tell the two apart is to write things down. Keep a short note of your symptoms and any side effects, with dates. Women who arrive at a review with a few lines of record get far more out of the appointment than women who arrive with a general impression, because the pattern across weeks is what shows whether something is settling or not.

Practical snags are worth raising rather than living with. A patch that will not stay stuck, a gel that feels fiddly, a spray that is easy to forget: all are reasons to talk about a different form within the same route, not reasons to abandon treatment. And if you are thinking of stopping, ask how best to do it rather than simply halting. A review is the natural place to raise all of this, and it is worth asking when yours will be.

What should you discuss with your doctor about HRT?

Guidelines, including NICE NG23, recommend a personalised decision after a discussion of benefits and risks. Useful questions to ask: do I still have my uterus? Are my symptoms mainly vaginal or also general? Do I have migraine, high blood pressure, a raised body mass index or a history of clots? If you have vascular risk factors, the transdermal route is often the first choice, and the choice of progestogen depends on tolerance, sleep and mood, which is why several options exist.

There is rarely a wrong first choice, but there is always a choice that needs adjusting over time. Keep a note of your symptoms and any side effects, and review the regimen with your clinician after a few months, because your needs can change.

Questions worth having answered before you start:

The consultation where hormone therapy is agreed is a good place to be direct. These are the questions that make the next few months easier, whichever regimen you end up on.

• Which hormone am I taking, and what is each part doing?
• What should this regimen change for me, and what should it not be expected to change?
• What side effects are common enough that I should expect them, and which ones mean I should call you?
• How do we tell whether it is working, and when do we review it?
• What happens if I forget a dose, or if I miss a day or two?
• Do I need to change anything about the other medicines I take?
• What are my options if this one does not suit me?

It also helps to say what you actually want from treatment. If the goal is uninterrupted sleep rather than fewer hot flashes, that changes which option is tried first. A clinician can only aim at a target you have described, and stating yours plainly is not being demanding. It is giving them the information they need.

In short:

HRT comes in different oestrogens, different progestogens and different regimens, and the right combination depends on you. Women with a uterus need progestogen to protect the uterine lining, and transdermal forms carry a lower clot risk than oral ones. Talk openly with your clinician about symptoms, risks and preferences, because the choice is made together and a well-tuned regimen can be adjusted at any time.