HRT types and routes: tablets, patches, gels, sprays and implants

Systemic HRT replaces oestrogen that the ovaries produce less of around the menopause. If you have a womb, taking oestrogen alone would thicken the lining and raise the risk of womb cancer, so a progestogen is added. If you have had a hysterectomy, oestrogen alone is usually enough. Some preparations combine both hormones in one product; others are taken separately.

Sequential (cyclical) regimens give oestrogen every day and add progestogen for part of each month, which usually leads to a monthly bleed. They are often used in perimenopause, when periods are still occurring. Continuous combined regimens give both hormones every day and are intended to avoid monthly bleeding; they are generally used after a year or more without periods, or after age fifty-ish according to the product information, because starting too early can cause irregular bleeding. Your prescriber chooses based on your stage and preferences.

NICE guidance explains that the risk of blood clots is not increased with transdermal oestrogen at standard doses, while oral oestrogen carries a small increase. For people with additional clotting risk, such as obesity or a family history, this can influence the choice. Oral tablets also pass through the liver first, which affects some blood tests and interacts with certain medicines.

Options include micronised progesterone taken orally, progestogens within combined patches or tablets and the levonorgestrel intrauterine system, which sits in the womb and delivers a progestogen locally while you take oestrogen separately. Some people tolerate one progestogen better than another when it comes to mood or bloating. If side effects are troublesome, ask about changing the type or route.

HRT is not contraception. People who could still become pregnant need separate contraception unless the intrauterine system is in place and licensed for that purpose. Guidance suggests continuing contraception for a period after the last period, which depends on age. Ask your clinician how long that should be for you.

Many clinicians start with a standard or low dose and adjust at review. It can take a few weeks to see an effect and a few months to settle. Keep a symptom diary before starting, and note any bleeding patterns. If you are uncertain between products, ask for a trial of one route and review, rather than switching frequently.