Types of Hormone Therapy
Menopausal hormone therapy (MHT) is available in different forms, doses, and routes of delivery. Some treatments work throughout the body, while others act primarily in a specific area.
The most appropriate option depends on the symptoms being treated, whether you have a uterus, your medical history, personal preferences, and other individual health factors. Understanding how the different forms of MHT are delivered can help you have a more informed conversation with your healthcare provider.
Systemic vs. Local Hormone Therapy
Systemic Hormone Therapy
Systemic hormone therapy enters the bloodstream and circulates throughout the body. It is commonly used to treat symptoms such as hot flashes and night sweats and can also help prevent bone loss.
Systemic estrogen may be delivered through:
- Tablets or capsules
- Skin patches
- Gels
- Sprays
For women with a uterus who use systemic estrogen, a progestogen is generally also prescribed to help protect the uterine lining.
Local Hormone Therapy
Local therapy delivers treatment primarily to a specific area of the body. Low-dose vaginal estrogen, for example, acts mainly on vaginal and urinary tissues and generally results in much lower systemic estrogen exposure than systemic therapy.
This is commonly used for symptoms of genitourinary syndrome of menopause (GSM), including vaginal dryness, irritation, discomfort with sex, and some urinary symptoms.
Oral
Oral hormone therapy is taken by mouth and absorbed through the digestive system. It passes through the liver before entering the general circulation, a process known as first-pass metabolism.
Common forms: Tablets and capsules.
Things to consider: Oral estrogen can be effective for treating systemic menopause symptoms, but because it passes through the liver, its effects on blood clotting and certain metabolic processes differ from transdermal estrogen.
Transdermal
Transdermal hormone therapy delivers hormones through the skin and into the bloodstream. Because it bypasses first-pass metabolism in the liver, it affects some clotting and metabolic pathways differently from oral estrogen.
Common forms: Patches, gels, and sprays.
Things to consider: Transdermal estrogen may be preferred for some women based on individual health factors and risk profile. The choice of route should be discussed with a healthcare provider.
Local Vaginal Hormone Therapy
Low-dose vaginal estrogen delivers estrogen directly to vaginal and surrounding tissues. Systemic absorption is generally low compared with systemic hormone therapy.
It may help relieve symptoms such as:
- Vaginal dryness, burning, or irritation
- Pain or discomfort during sex
- Some menopause-related urinary symptoms
Common forms: Vaginal creams, tablets/inserts, and rings.
Things to consider: Local vaginal estrogen is primarily used for genitourinary symptoms rather than symptoms such as hot flashes and night sweats.
Hormones Used in Menopause Hormone Therapy
Estrogen
Estrogen is the primary hormone used in menopausal hormone therapy. It can help relieve symptoms such as hot flashes and night sweats and can help prevent bone loss.
Estrogen may be used systemically through tablets, patches, gels, or sprays, or locally in the vagina for symptoms such as dryness, irritation, and discomfort.
Progestogen
For women with a uterus who use systemic estrogen, a progestogen is generally added to help protect the uterine lining from endometrial overgrowth.
Progesterone and synthetic progestins are available in different formulations, and the appropriate option depends on the individual treatment plan.
Testosterone
Testosterone is not routinely used to treat general menopause symptoms. Its clearest evidence is for appropriately diagnosed hypoactive sexual desire disorder (HSDD) in postmenopausal women.
There is currently no FDA-approved testosterone product specifically indicated for women in the U.S., so treatment requires individualized dosing and monitoring.
Selective Estrogen Receptor Modulators (SERMs)
Selective estrogen receptor modulators (SERMs) are not hormones, but they interact with estrogen receptors in the body. They can act like estrogen in some tissues while blocking estrogen's effects in others.
This selective action allows certain SERMs to be used for specific menopause-related concerns, including bone health and vaginal symptoms.
Examples include:
- Bazedoxifene – combined with conjugated estrogens in an FDA-approved menopausal hormone therapy for women with a uterus. Bazedoxifene helps protect the uterine lining, allowing the combination to be used without a progestogen.
- Ospemifene – a non-estrogen treatment used for certain symptoms of genitourinary syndrome of menopause (GSM), including moderate to severe vaginal dryness and pain with intercourse.
SERMs have different effects, benefits, and risks depending on the medication and how it is used. Treatment should be individualized with a healthcare provider.
Bioidentical Hormones
Bioidentical hormones are chemically identical to hormones naturally produced by the human body. FDA-approved hormone therapies containing bioidentical estradiol and micronized progesterone are available in several forms and doses.
The term “bioidentical” is sometimes associated with compounded hormone therapy, but they are not the same. Bioidentical hormones can be found in both FDA-approved products and compounded preparations.
Compounded Hormone Therapy
Compounded hormone therapies are custom-prepared by compounding pharmacies and may contain hormones such as estradiol, progesterone, or testosterone. They are sometimes marketed as “bioidentical” or customized hormone therapy.
It is important to distinguish compounded products from FDA-approved bioidentical hormone therapies. FDA-approved products containing hormones that are chemically identical to hormones produced by the body, including estradiol and micronized progesterone, are available in standardized formulations.
Compounded hormone therapies:
- Are not FDA-approved
- May have greater variability in potency and consistency
- Have not undergone the same premarket testing for safety and effectiveness as FDA-approved hormone products
- May be appropriate in certain circumstances when an FDA-approved formulation does not meet an individual patient's needs
FDA-approved hormone therapy is generally preferred when an appropriate approved product is available.
Choosing the Right Type, Dose, and Route
There is no single form of hormone therapy that is right for everyone. Treatment should be individualized based on your symptoms, medical history, age, time since menopause, whether you have a uterus, and personal preferences.
Your healthcare provider can help determine:
- Whether systemic or local treatment is most appropriate
- Whether estrogen alone or estrogen with a progestogen is needed
- Which route of administration best fits your needs
- An appropriate dose
- How your treatment should be monitored and reviewed over time
The goal is to use an appropriate effective dose, with treatment periodically reassessed as symptoms, health needs, and individual risk factors change.
Final Thoughts
Menopausal hormone therapy is available in several forms, and the route of delivery can influence how hormones are absorbed and how treatment affects the body. Understanding the differences between oral, transdermal, and local therapies can make it easier to discuss your options with your healthcare provider.
The right approach is individual and may change over time as your symptoms, health, and treatment goals evolve.
Key Takeaways
✓ Hormone therapy can be systemic or local, depending on the symptoms being treated.
✓ Oral estrogen passes through the liver, while transdermal estrogen is absorbed through the skin and bypasses first-pass liver metabolism.
✓ Low-dose vaginal estrogen primarily treats vaginal and urinary symptoms and generally results in low systemic exposure.
✓ Women with a uterus generally need a progestogen with systemic estrogen to protect the uterine lining.
✓ Treatment should be individualized, taking into account symptoms, medical history, preferences, dose, and route of administration.
The right hormone therapy depends on the hormones, delivery method, and your individual needs.
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Medical Disclaimer
The information on this page is provided for educational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment.
The appropriate type, dose, and route of hormone therapy vary from person to person. Benefits and risks depend on factors including your symptoms, age, medical history, whether you have a uterus, and the specific treatment being considered. Always consult your healthcare provider before starting, stopping, or changing hormone therapy or other treatments.
Seek prompt medical attention for severe, sudden, or concerning symptoms or any medical emergency.