While the increased awareness of menopause in recent years is no doubt helpful, there can be so much information about treatments that it is overwhelming at times to understand what is right for you. The more you read about HRT, the more confusing it can be to understand all the different medications and make a decision about how you choose to manage your symptoms.
The decision on what type of HRT is for you is best made in partnership with your menopause clinician and should align with your lifestyle and aims for treatment.
If you already know the type of HRT you’re going to take, you may wish to read our guide on Starting Hormone Replacement Therapy.
HRT Back to Basics
Peri/menopause symptoms are caused by fluctuations and then a decline in these 3 key hormones:
- Estrogen
- Progesterone
- Testosterone
Hormone Replacement Therapy is giving your body back these hormones to help replenish and balance the hormone levels in your blood that affect your whole body and all its functions.
There are different types of these 3 hormones, and different ways to take them. Think of estrogen and progesterone as a working pair because, for most women (unless you don’t have a womb), you will need to take progesterone if you’re taking estrogen. Testosterone is often considered the one that is added in later if you haven’t found enough benefit from the estrogen and progesterone.
Usually, when we talk about HRT, we are referring to any one or combination of these hormones and they all enter the bloodstream and circulate the whole body. This is why it is also known as ‘systemic’ HRT.
There is another type of hormone replacement that is just for symptoms affecting the genitals and urinary function that is only administered in and around the vagina, hence it is referred to as vaginal estrogen or local estrogen. We will cover this type at the end of this booklet.
Combined vs Estrogen only HRT
As mentioned, most women who take estrogen also need to take a progesterone treatment because taking estrogen can thicken the lining of the womb and increase the risk that some cells may ‘over-grow’ and become cancerous. Progesterone keeps the lining healthy and minimises any risk. Taking estrogen and progesterone is called Combined HRT.
If you don’t have a uterus because you had a hysterectomy, then you will usually only need to take estrogen on its own and this is called Estrogen-only HRT. (You may still want to add testosterone replacement but this is considered separately to the estrogen treatment).
A couple of exceptions to this are:
- if you have endometriosis and have had a hysterectomy, your gynaecologist may recommend taking a progestogen to avoid any potential remaining patches of disease being stimulated by the estrogen.
- if you have had a ‘subtotal’ hysterectomy and have kept the cervix rather than have all of the womb removed, you may need to still take a progesterone.
- if you have had endometrial ablation as a treatment for heavy periods, the lining of the womb is not totally removed, therefore you will most likely still require a progesterone treatment to keep the lining thin and healthy.
Sequential vs Continuous HRT
You may have come across the terms Sequential (or cyclical) HRT and Continuous HRT. These just refer to the two ways to take the progesterone part of your HRT. And it depends on whether you’re still having periods or not.
Sequential HRT
If you have had a period in the last 6-12 months, it will usually be recommended to have sequential HRT. This involves taking estrogen every day and progesterone for 12-14 days out of every 28.
For simplicity, women are usually advised to take the progestogen in a pattern of 2 weeks on, 2 weeks off, which will usually result in a monthly bleed when you are ‘off’ the progesterone.
Continuous HRT
If your last period was 12 months ago or more, it will be recommended that you start continuous combined HRT. This involves taking both estrogen and progesterone every day, all throughout the month continuously.
Some vaginal bleeding is common when you first start this regime but usually settles within 3-6 months, after which no bleeding is expected.
Note: Both these ways of taking progesterone refer to the types of progesterone that come in tablets, capsules, and patches. Many women choose to get their progesterone from an intrauterine system (IUS or coil) instead, which releases progesterone continuously for 5 years. More on this later.
Types and ways to take Estrogen
Estradiol is the type of estrogen used in HRT and it is derived from plant-based ingredients and mimics the natural estrogen produced in the body.
The most common way to take estrogen as part of HRT is through the skin, known as transdermal estrogen. This can be via a patch, gel, or spray.
Patches are similar to plasters that you peel off and stick to the skin. They come in varied strengths from 25 to 100 micrograms so you can start on a dose best suited to you and it can be changed as needed after a few months trial.
The gel comes in a pump action bottle (or sometimes a sachet) that you apply to the skin and the dose is given by the number of pumps to apply. This might be anywhere between 1-4 pumps daily and can easily be adjusted if symptoms are not controlled.
Less commonly used is a spray that delivers estrogen to the skin and this can be used with 1-3 sprays per day.
Estrogen can be taken orally as a tablet that you swallow and some women prefer to do this rather than apply preparations to the skin. Some oral estrogens are the same estradiol that is given via the skin and is identical to that produced in the body.
Combination patches and tablets are those that have both the estrogen and progesterone parts of HRT together in the same medication, which can be helpful if you don’t want to have to deal with two different medications. It can be more difficult however to change the estrogen dose if needed when using combination methods.
To help you decide whether you would like to take your estrogen via a patch, gel, spray or tablet, have a look at our table below:
| Type | Application | Pros | Cons |
| Gels | Applied once daily to clean dry skin on the upper outer arm or inner thigh | Easy to use
Flexibility of dose No visible sign of HRT treatment |
Needs to be left to dry for 5 minutes before dressing
Higher doses can require a large area of skin for application Need to avoid close skin-to-skin contact with others for 1 hour to avoid transfer |
| Patches | Applied to clean, dry, non-hair bearing skin below the waist and usually changed twice weekly (FemSeven is changed once weekly) | Easy to apply
Delivers a steady dose of estrogen so can be useful for migraine Twice weekly application only rather than daily No need to wait before dressing |
Can leave residue of glue when patch is peeled off
Some women react to the glue and develop itchy red patches Some women do not like the visibility of the patch when in underwear or swimwear |
| Spray | Applied once daily to the inner aspect of the forearm | Easy to apply
Only 2 minutes to absorb Smaller area of application |
Need to avoid close skin-to-skin contact with others for one hour to avoid transfer |
| Tablet | Swallowed daily | Easy and convenient
Not visible to others No need to wait after taking |
If taken as combination tablet, less easy to adjust dose |
Top tips for applying transdermal estrogen:
Estrogen Gel
- Gel should be rubbed in with a similar effort required to apply moisturiser
- Apply to a large area – either the inner thighs or upper outer arms
- Wash your hands after application
- Allow 5 minutes after application before getting dressed
- Allow 60 minutes before using any other skin application including sun cream
- Allow 60 minutes before close skin-to-skin contact with another person
- If another person, particularly a child, touches the area of application before 60 minutes has elapsed, tell the person to wash the area with soap and water immediately
- Do not let pets touch or lick the site of application
- Return empty containers to the pharmacy for safe disposal
Estrogen Patches
- Remove patch from packet and peel back one half of the protective backing
- Avoid contact with the adhesive
- Apply to clean, dry, non-hair bearing skin below the waist. Skin should be free of powder, oil, moisturiser or lotion
- Most women apply to the buttock, hip, upper thigh or lower abdomen
- Roll the patch onto the skin while removing the second part of the protective backing
- Ensure the patch is flat and adhering well
- Press the patch firmly in place with the palm of your hand for about 20 seconds
- Change twice weekly – alternating sides of body and area of application
- Baby oil is good for removing any residue of glue, or there are sprays specifically for this purpose
- Patches can be worn in the shower, bath, during exercise or swimming
- When changing the patch, peel it off and fold it in half with the sticky side inwards and dispose of safely
Estrogen Spray
- Before using a new spray bottle for the first time, prime the pump by spraying 3 times with the cover on. Hold the container upright while doing this
- Apply to healthy, clean, dry skin of the inner forearm
- Each day, remove the plastic cover, hold the spray upright, and rest the plastic cone flat against the skin of your inner forearm
- Ensure there are no gaps between the cone and your skin
- Push the button down fully, hold and release
- If another spray is needed, move the cone along the forearm so that it is beside the area that has already been sprayed
- Avoid overlap of the areas
- Push the button down fully, hold and release
- Repeat if 3 sprays are prescribed
- Allow 2 minutes for the spray to dry
- Allow 60 minutes before close skin-to-skin contact with another person
- If another person, particularly a child, touches the area of application before 60 minutes has elapsed, tell the person to wash the area with soap and water immediately
- Do not let pets touch or lick the site of application
- If sun cream is required to the area of application, apply 1 hour after application of estrogen spray
- Return all empty sprays to the pharmacy for safe disposal
Are there any risks associated with estrogen replacement?
Breast cancer is often the most common worry for women when thinking about taking HRT but the reality is your personal breast cancer risk depends on many factors including age, family history, your weight, if you smoke, how much alcohol you drink and whether you exercise regularly.
Studies have shown that women who take estrogen-only HRT do not have any increased risk of breast cancer.
Women who take combined HRT (both estrogen and progestogen), may have a very small increased risk of breast cancer, but this risk can be minimised further by using micronised progesterone which is described more in the Progesterone section.
If you’d like to read more about this, you can read our guide, Understanding HRT and Breast cancer risk.
Estrogen absorbed through the skin via a patch, gel or spray does not increase the risk of developing a blood clot as it bypasses the liver. Estrogen taken orally as a tablet does have a small increased of clot if it is the synthetic type of estrogen.
As we age, our risk of getting a blood clot increases so reducing this risk becomes more important. If you are overweight or obese, you smoke or take little exercise, you are increasing your risk of a blood clot. You can find out more in our guide on Keeping Your Heart Healthy.
Types and ways to take Progestogen
If you have a uterus and take estrogen replacement, you will most likely need to ensure you also take a progesterone to keep the womb lining thin and healthy.
As mentioned, you can take the progesterone part in the same tablet or patch as the estrogen part of your HRT but this doesn’t always allow for the best tailoring of the doses of the two hormones. Each woman has unique needs and ways of responding to HRT and it is common for your menopause clinician to suggest changes to the dose or form of the hormone medications in order to get the best response.
The ways most women on HRT receive progesterone is either via an oral capsule that is known as micronised progesterone or by an intrauterine system/coil.
Micronised Progesterone
Micronised progesterone is chemically identical to the progesterone produced by the ovary and is derived from the yam root vegetable. In the UK, the brand names are Utrogestan® or Gepretix®.
Micronised progesterone has several advantages over synthetic progestogens:
- It is more selective in where it acts in the body leading to less side effects
- It is often better tolerated
- It has a sedative effect when taken orally so when taken at night, it can help sleep
- It is calming and can be helpful at reducing anxiety
- Studies have shown that micronised progesterone is associated with a lower breast cancer risk than synthetic progestogens
- There is no increased risk of clot with micronised progesterone
Micronised progesterone can be used alongside an estrogen patch, gel or spray and in either a sequential (cyclical) or continuous combined HRT regime.
Top tips for using micronised progesterone:
- Micronised progesterone should ideally be taken on an empty stomach
- Take it 30-60 minutes before bedtime, the sedative effect will help you sleep
- If taken as part of sequential HRT, micronised progesterone is usually taken as 2 capsules at night for 12-14 days out of 28. For convenience, women are usually advised to take it in a pattern of 2 weeks on, 2 weeks off.
- If taken as part of continuous combined HRT, micronised progesterone is usually taken 1 capsule at night, every night. (Some women may benefit from taking it for 25 nights out of 28).
IUS or coil
The intrauterine system (IUS) or coil as it is often known, is a small T-shaped plastic device that is inserted into your womb (uterus) that slowly and steadily releases a hormone called levonorgestrel, a type of progestogen. In the UK, the Mirena® or Levosert® are the most common hormonal coils used as part of HRT.
The coil is inserted by a health professional at your GP practice, sexual health clinic or in a gynaecology outpatients department. The level of discomfort experienced during this procedure varies greatly from woman to woman and you can discuss ways to reduce pain with your clinician if this is causing anxiety for you.
There are two threads attached to the coil that pass out through the cervix and lie inside your vagina. You can check the coil is in the right place by feeling for these threads, and they are also used for removal when needed. The threads don’t hang outside the body and are not visible.
Women often choose the coil for the following reasons:
- Once it’s in, you don’t need to remember to take a daily progesterone tablet
- It can significantly reduce menstrual blood loss, which is particularly helpful if your periods have become heavier or unpredictable during perimenopause
- It also serves as an effective form of contraception if needed
- It works as the progesterone part of your HRT for 5 years.
Are there any risks associated with progesterone replacement?
Micronised progesterone is the safest type of progesterone for minimising the small risk of breast cancer associated with HRT use. It has no additional risk of blood clot, and helps to maintain the beneficial effects of estrogen on lipids and sugar metabolism. Many women like the benefit of an improved night’s sleep due to its calming effects.
Hormonal coils can cause some side effects particularly when first inserted, similar to that of pre-menstrual syndrome, such as low mood, tearfulness, bloating and tender breasts. If you want to read more about these reactions to progesterone, see our guide on Progesterone Intolerance.
Types and ways to take Testosterone
Levels of testosterone in women often decline steadily with age and can contribute to low libido, a lack of energy and mental clarity or stamina. Currently, guidelines recommend the use of testosterone in menopausal women only for persistent low libido after HRT has been commenced. However, many women who take testosterone report not only improved sexual interest and arousal but also improved muscle and bone strength, energy levels, cognitive function, mood and concentration, reduced brain fog and better sleep.
There is only one licensed form of testosterone for women in the UK (Androfeme®), this is normally prescribed privately as the NHS eligibility criteria for prescribing this are relatively narrow. Because of this, testosterone prescribed by menopause doctors is done ‘off label/off license’ and very small doses of male testosterone gel is used for this purpose (such as Tostran® or Testogel®).
Top tips if using Testosterone gel:
- Apply once daily to the outer thigh, buttocks or lower abdomen
- Use on areas of skin that do not have a lot of hair
- Rotate the exact spot you’re applying the gel every day
- Use exactly as prescribed, in the small pea size amount your doctor described
- Have a blood test after 3 months of starting testosterone and then yearly after that to check that your levels remain well within the ‘female’ range.
We have lots more information in our booklet Testosterone for Women.
Localised vaginal estrogen
While this isn’t strictly considered HRT, it is often used as an addition to HRT if that alone has not improved symptoms of vaginal dryness, discomfort and urinary problems.
Other symptoms it can improve are vaginal itch, soreness, pain on intercourse, frequent passing of urine, urine leakage, getting up in the night to pass urine, recurrent urinary tract infections, cystitis and thrush.
Vaginal estrogen comes in various forms for example, as a tablet, pessary, gel, cream or ring. In this table, we compare these forms and give you the pros and cons to help you decide what would be best for you.
| Type | How is it used | Pros | Cons |
| Tablet
Vagifem, Vagirux GinaTM |
Inserted high into the vagina using an applicator for 2 weeks and then continued twice weekly
Usually inserted at night |
No mess
Easy to use Vagirux has a reusable applicator so more environmentally friendly Gina has been made available to buy without prescription if over 50 years and no periods for 12 or more months |
Vagifem has a daily plastic applicator that is disposed
Vagirux requires the small tablet to be reloaded into the applicator so good eyesight and coordination are required |
| Pessary
Imvaggis |
Inserted into the vagina using the fingers
Used once daily for 3 weeks and then continued twice weekly |
No applicator so no waste
The pessary is waxy which can aid dryness with its lubricating properties |
Can damage latex condoms therefore other contraception is advised
Can produce a slight waxy discharge |
| Cream
Estriol 0.01% |
Inserted into the vagina once daily for 2 weeks and then continued twice weekly
|
Can be quite soothing if the vagina is very dry
Can be spread on the vulva if this is dry and sore |
Can be messy
Estriol cream contains peanut oil and should be avoided by those with peanut allergies (including in partners) Can damage latex condoms therefore other contraception is advised |
| Gel
Blissel |
Inserted into the vagina once daily for 3 weeks and then continued twice weekly | Gel is rapidly absorbed | Itching or irritation may occur when first used |
| Ring
Estring |
Inserted into the vagina by the user herself or by a healthcare professional | Stays in place for 90 days
No daily or weekly treatment |
Doesn’t usually interfere with sex but if it does, it can be removed before and replaced afterwards |
Other types of vaginal estrogen
Intrarosa is a pessary that does not contain estrogen but does contain prasterone which is converted to estrogen and testosterone in the vaginal cells. It can be used once daily in the vagina to help women who are suffering with vaginal or bladder symptoms related to menopause. It is easy to use but can damage latex condoms therefore other contraception is advised if needed.
Vaginal estrogen and need for progesterone
If you do not take any other form of estrogen and are going to start using only vaginal estrogen, there is no need to also take a progestogen as the amount of estrogen absorbed is so low that it doesn’t stimulate the lining of the womb.
For further information, please see our resources on Vaginal Dryness and Genitourinary Syndrome of Menopause. You might also like to read our blog on How your vulva changes during menopause.
Last updated: June 2026
