Different types of hormone therapy (HRT): Which one is right for you?

Table of contents

1. Why there are so many options

2. Oestrogen

3. Progesterone

4. Combined therapies

5. Testosterone

6. Local vs systemic therapy

Why there are so many options for hormone therapy

If you’ve ever googled “hormone therapy,” you know how overwhelming it can be: pills, patches, gels, rings, where do you even start? It makes sense that there are so many choices. Every woman experiences menopause differently, and every body responds in its own way. Hormone therapy, just like contraception, is very personal. If insomnia is your main symptom, you may need a different approach than someone dealing with dryness or pain during sex. There are also different delivery methods such as pills, sprays and patches. These days, most doctors prefer transdermal oestrogen, in the form of a patch or spray. Pills are prescribed much less often. This is also why prescribing hormone therapy can be challenging for GPs. When you start HRT, your body needs time to adjust, which means finding the right dose. That process can take time, sometimes even up to a year. Most women start with a low dose, since some people don’t break down oestrogen efficiently and can develop side effects if the dose is too high. The dosage is then gradually increased until the balance feels right. Sometimes it’s necessary to switch types - for example, some women develop skin irritation from patches and move to a spray or pill instead. Different forms can also be combined, such as transdermal and vaginal oestrogen, or adding testosterone when needed. The conclusion is that hormone therapy is highly individual.

A quick note…

We often see women who stopped HRT because they felt it “wasn’t for them.” They may have experienced side effects, worsening symptoms, or no improvement at all. Some heartbreaking stories involve women who struggled with severe symptoms for over a decade because their initial treatment wasn’t properly tailored. Many GPs still prescribe the standard options, but the guidelines they follow are sometimes outdated. For instance, the current GP guideline still lists the non-bioidentical combined pill (Femoston) as a good option, while the Dutch Society for Obstetrics and Gynaecology (NVOG) no longer recommends it as first choice. If you’ve tried hormone therapy in the past but weren’t satisfied and still have symptoms, it might be worth getting updated advice and better guidance.

Oestrogen

Oestrogen is the foundation of most HRT treatments because its decline causes many of the typical menopausal symptoms such as hot flashes, night sweats, mood swings, poor sleep and vaginal dryness. Ways to take oestrogen:

• Tablets: Simple and familiar, but since they go through the digestive system and liver, they slightly increase the risk of blood clots. Combined pills with oestrogen and progesterone, like Femoston, are still used in the Netherlands, but they are non-bioidentical.

• Patches: Applied to the skin and release hormones gradually. They are usually replaced twice a week and often cause fewer side effects.

• Gels and sprays: Applied daily to the skin, usually on the arm or thigh. They make it easy to start with a low dose and adjust when needed.

• Vaginal oestrogen: Comes as creams, gels, tablets or rings applied directly to the vagina. These act locally and are very effective for dryness, itching, pain during sex or urinary discomfort. Because the dose is low, they are considered very safe.

Progesterone

If you still have a uterus, you cannot take oestrogen on its own. Without progesterone to balance it, the uterine lining can thicken, increasing the risk of endometrial cancer. Progesterone protects the uterus and also supports better sleep and emotional calm for many women. Forms of progesterone:

• Micronised progesterone (for example, Utrogestan): Considered the gold standard because it most closely resembles your body’s natural progesterone and is generally better tolerated.

• Synthetic progestogens: Sometimes used, but they may cause more side effects like mood changes or a slightly higher breast cancer risk.

• Hormonal IUD: Delivers progesterone directly into the uterus, helps reduce heavy bleeding and also acts as contraception, which is useful in early perimenopause when pregnancy is still possible.

Combined therapies

Since most women need both hormones, there are also combination options.

• Cyclic therapy: Oestrogen daily, with progesterone added for 10–14 days each month. This often causes a monthly bleed, similar to a period.

• Continuous therapy: Both hormones are taken every day, which stops bleeding altogether. This is usually started after you’ve gone at least a year without a natural period.

Your phase of menopause will determine which option fits best, and sometimes women transition from one approach to another over time.

Testosterone

It might surprise you, but women also produce testosterone. It supports energy, mood and especially libido. For some women, a small amount of testosterone can help when standard HRT doesn’t fully restore sexual desire or vitality. Testosterone for women isn’t officially available everywhere, so specialists often prescribe it off-label in gel or cream form. It must always be monitored carefully, as women require much smaller doses than men. Regular blood tests are needed to make sure levels don’t rise too high, so it’s a treatment that should always be managed by an experienced professional.

Vaginal oestrogen

Vaginal oestrogen is different from systemic oestrogen and works mainly in the vaginal and bladder area. Because almost none enters the bloodstream, it’s considered safe even for many women who cannot use systemic HRT, such as those with a history of breast or ovarian cancer. It’s also highly effective for treating GSM, or Genitourinary Syndrome of Menopause, also known as vaginal atrophy. This condition affects a large number of women, causing thinning of the vaginal and vulval tissues, sometimes even shrinking of the labia and clitoris. The discomfort can be significant, but local oestrogen treatment often brings relief and is safe to use long-term. In some countries, it’s even available over the counter.

Bioidentical vs synthetic hormones

The term “bioidentical hormone therapy” (BHRT) is everywhere these days, but what does it mean? Bioidentical hormones aren’t harvested from plants or cloned in nature - they’re produced in a lab, just like synthetic hormones. The difference is in their molecular structure, which is identical to the hormones your body naturally makes. Because of this, they’re absorbed better and tend to cause fewer side effects. If they’re so much better, why are synthetic hormones still used? In contraception, it makes sense. Synthetic hormones are designed to prevent ovulation or implantation. For example, progestin is used in the combination pill and hormonal IUDs like Mirena or Kyleena. But for hormone therapy, bioidentical forms are generally preferred.

The pill as hormone therapy

Many women continue taking the pill through menopause and use it as a form of hormone therapy. Whether that’s a good idea depends on your situation. The combined pill is always synthetic, because it’s designed to suppress ovulation. If you’ve always tolerated it well, continuing may be an option. However, bioidentical hormone therapy is often a better fit for menopausal symptoms, since the pill wasn’t designed for this purpose. Think of it as using a forklift to lift a six-pack onto the counter - it works, but it’s not ideal. The pill also carries a slightly higher risk of blood clots compared to transdermal hormone therapy.

Key takeaways

• Oestrogen is usually central, but progesterone also plays an important role in overall wellbeing.

• There are tablets, patches, gels, sprays and vaginal options, each with their own pros and cons.

• Micronised progesterone and transdermal oestrogen are often considered the safest long-term choices.

• Testosterone can be helpful for low libido, but only under specialist supervision.

• Local vaginal oestrogen therapy is safe and very effective for dryness, itching and urinary symptoms.

References:

de Villiers, T. J., Hall, J. E., Pinkerton, J. V., Cerdas Pérez, S., Rees, M., Yang, C., & Pierroz, D. D. (2016). Revised Global Consensus Statement on Menopausal Hormone Therapy. Climacteric, 19(4), 313–315. https://doi.org/10.1080/13697137.2016.1196047

Nederlands Huisartsen Genootschap. (2024). NHG-Standaard: De overgang (M73) (versie 3.1; revisiedatum 22 februari 2024). https://richtlijnen.nhg.org/standaarden/de-overgang

North American Menopause Society. (2022). The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 29(7), 767–794. https://doi.org/10.1097/GME.0000000000002028

Wiersma, T., & van der Weijden, T. (2023). Update praktische handleiding hormoonsuppletietherapie (HST). De Menopauzespecialist. https://demenopauzespecialist.nl/update-praktische-handleiding-hormoonsuppletietherapie-hst/