Types of Menopausal Hormone Therapy: Pills, Patches, Gels, and More

"Hormone therapy" isn't one product—it's a menu of hormones, doses, and delivery routes that a clinician assembles around your symptoms and history. Two choices define most regimens: which hormones you take (estrogen alone, or estrogen plus a progestogen) and how they enter your body (a systemic route that treats whole-body symptoms, or a local one that treats vaginal and urinary symptoms). This guide maps the menu so the options a provider proposes—online or in person—make sense.

Estrogen Alone vs. Estrogen Plus a Progestogen

The first fork in the road is anatomical. If you've had a hysterectomy, estrogen-only therapy is typically appropriate. If you still have a uterus, estrogen must be paired with a progestogen (progesterone or a synthetic version), because unopposed estrogen stimulates the uterine lining and raises the risk of endometrial cancer. The progestogen can be taken continuously or cyclically, and some FDA-approved products combine both hormones in a single pill or patch. This isn't a preference question—it's a safety rule, and any service that prescribes estrogen without asking about your uterus is cutting a corner.

Systemic Therapy: Pills, Patches, Gels, and Sprays

Systemic therapy raises hormone levels throughout the body and is what treats hot flashes, night sweats, and bone loss. The main routes:

• Oral tablets — the longest-studied route; processed through the liver first
• Transdermal patches — steady delivery through the skin, bypassing the liver; observational evidence suggests a lower blood-clot risk than oral estrogen
• Gels and sprays — applied to the skin daily, also transdermal
• Higher-dose vaginal rings — one ring (such as the systemic-dose type) delivers whole-body estrogen for about three months

Effectiveness for hot flashes is broadly similar across routes at equivalent doses; the choice usually comes down to your risk profile, convenience, skin tolerance, and cost.

Local (Vaginal) Therapy: Creams, Tablets, and Rings

If your symptoms are primarily genitourinary—dryness, irritation, pain with intimacy, recurrent urinary discomfort—low-dose vaginal estrogen creams, tablets, inserts, and rings treat the tissue directly with minimal absorption into the bloodstream. Local therapy does not treat hot flashes, and because so little hormone circulates, guidelines generally do not require a progestogen alongside it even with an intact uterus. Many people are candidates for local therapy who wouldn't be candidates for systemic treatment.

FDA-Approved vs. Compounded "Bioidentical" Hormones

Here's a distinction worth understanding before you compare providers. FDA-approved hormone therapies—including several made with body-identical estradiol and micronized progesterone—are tested for safety, effectiveness, dose consistency, and quality. Compounded "bioidentical" hormones, mixed by pharmacies into custom creams, capsules, or pellets, are not FDA-approved: the FDA does not review them before marketing, and ACOG advises against routinely prescribing them when approved alternatives exist, citing variable potency and limited safety data. Compounding has legitimate uses (for example, a documented allergy to an ingredient in approved products), but "bioidentical" marketing alone isn't evidence of safety. If a service prescribes compounded hormones, ask why an FDA-approved option wasn't chosen first.

How a Clinician Matches Type to Patient

In practice, the regimen falls out of a short series of questions: Do you have a uterus? Are your symptoms whole-body or local? Does your history (clots, migraine with aura, liver disease, cardiovascular risk) favor transdermal over oral? What dose is the lowest that controls symptoms? Expect a follow-up within a few months to adjust—getting the type right is usually iterative, which is one reason ongoing clinician access matters when you compare HRT services.