Hormone replacement therapy is delivered through pills, skin patches, gels, sprays, injections, implants, and vaginal preparations. The method you use affects how hormones enter your bloodstream, how often you need to take them, and your risk profile for certain side effects. Oral tablets remain the most common form, but transdermal options (through the skin) have become increasingly preferred because of their safer cardiovascular profile.
Oral Tablets
Pills are the most widely used form of estrogen therapy. You take them daily, and they’re absorbed through your digestive system before passing through the liver. This “first pass” through the liver is the key distinction between oral and other routes. It triggers changes in clotting factors and certain proteins, which is why oral estrogen carries a higher risk of blood clots compared to options that bypass the gut entirely.
Progesterone is also commonly taken as an oral capsule. The micronized form is better absorbed than standard versions, but oral progesterone still has limitations. Much of it gets broken down by the intestines and liver before reaching the uterus, and food intake interferes with absorption. For this reason, oral progesterone is typically taken at bedtime on an empty stomach, which also helps because it causes drowsiness.
Patches, Gels, and Sprays
Transdermal estrogen delivers the hormone directly through your skin into the bloodstream, skipping the liver entirely. This matters: a large study published in The BMJ found that oral HRT carried a 70% higher risk of blood clots compared to transdermal preparations. Transdermal estrogen showed no significant increase in clot risk at all compared to not using HRT.
Patches are applied to clean, dry, hair-free skin on the lower abdomen or upper buttocks. You replace them once or twice a week depending on the brand, rotating the application site each time and waiting at least a week before reusing the same spot. Some patches combine estrogen and a progestogen in a single patch.
Gels and sprays work the same way but require daily application. Estrogen gel is spread thinly over a large skin area, typically the inner and outer upper arm from wrist to shoulder, or across the hips, waist, abdomen, or thighs. After applying gel, you should avoid skin-to-skin contact with others for at least 60 minutes to prevent transferring the hormone, particularly to children, infants, or pets. Sprays are applied to the forearm in a similar daily routine.
Because of the lower clot risk, clinical guidelines from the North American Menopause Society recommend the transdermal route for women with moderate cardiovascular risk, those with diabetes, and situations where the lowest effective dose is the goal.
Injections and Implants
Estrogen can be delivered through small pellets inserted under the skin, typically in the buttock or lower abdomen, during a minor office procedure. These implants release a steady dose of estradiol and last 6 to 8 months before needing replacement. The advantage is consistency: you don’t have to remember daily or weekly dosing. The downside is that once inserted, the dose can’t be easily adjusted if side effects develop.
Intramuscular or subcutaneous estrogen injections are another option, though less commonly used than patches or pills. They’re typically given every one to two weeks and can cause hormone levels to fluctuate more noticeably between doses, with a peak shortly after injection and a gradual decline before the next one.
Vaginal Preparations for Local Symptoms
If your primary concern is vaginal dryness, discomfort during sex, or urinary symptoms, localized vaginal estrogen is generally recommended over systemic therapy. These preparations deliver estrogen directly to vaginal tissue with minimal absorption into the rest of your body.
The options differ mainly in how often you use them:
- Vaginal rings are inserted and left in place for 3 months, then replaced. You don’t need to remove them for intercourse.
- Vaginal tablets or inserts are used daily for the first 2 weeks, then reduced to twice weekly for ongoing maintenance.
- Vaginal creams follow a similar pattern. Some brands are applied daily for 2 to 4 weeks, then tapered to one to three times per week. Others use a rotating schedule that alternates several weeks of daily use with a week off.
Because these deliver such small amounts of estrogen locally, many women who can’t use systemic HRT can still safely use vaginal estrogen.
Testosterone for Women
Testosterone therapy is sometimes prescribed for postmenopausal women experiencing low sexual desire. The recommended form is a transdermal cream or gel applied to the back of the calf, upper outer thigh, or buttock. The starting dose for women is roughly one-tenth of what’s prescribed for men, typically around 5 mg daily, with the option to increase to 10 mg if needed.
Injections, pellets, and oral testosterone are not recommended for women because they’re more likely to push levels above the normal range, increasing the risk of side effects like acne, excess hair growth, and voice changes.
Cyclical vs. Continuous Schedules
Regardless of which delivery method you use, the dosing schedule for combined HRT (estrogen plus a progestogen) falls into two categories. Cyclical therapy means you take estrogen every day but add the progestogen for only 10 to 14 days each month. This produces a withdrawal bleed similar to a period each month. Continuous therapy means taking both hormones every day, with no planned bleeding.
Cyclical schedules are typically used for women still in the menopausal transition or those who are very recently postmenopausal and still having some irregular periods. Starting continuous therapy too early, before periods have fully stopped, often leads to unpredictable breakthrough bleeding. Continuous therapy is more commonly chosen by women who are further past menopause and prefer not to have monthly bleeds.
How the Route Is Chosen
The best delivery method depends on your health profile, your symptoms, and practical preferences. Women at elevated risk for blood clots, those who are overweight, smokers, or those with a history of migraines with aura are generally steered toward transdermal options. If you only have vaginal or urinary symptoms, local vaginal estrogen makes more sense than treating your whole body systemically. If convenience and not having to remember daily dosing matters to you, patches, rings, or implants offer longer intervals between doses.
The type, dose, route, and timing of HRT all independently affect both its benefits and its risks. Two women on “the same” therapy but using different delivery methods can have meaningfully different outcomes, which is why the administration route isn’t just a matter of preference. It’s a clinical decision that shapes how the therapy works in your body.