HRT types compared: patches, gels, tablets and vaginal estrogen
Hormone replacement therapy is not one product. It is a set of choices: which hormones, in what form, and by which route. This page lays those choices side by side so you can walk into an appointment with better questions. It is information, not medical advice.
Reviewed July 2026 against NICE, NHS and menopause-society guidance.
The short answer
The biggest practical difference between HRT types is how the estrogen reaches your body. Estrogen through the skin (a patch, gel or spray) is not linked to the higher blood-clot risk of estrogen tablets, so skin routes are often preferred if you have clot risk factors, migraine or a higher BMI. Local vaginal estrogen treats dryness and urinary symptoms with very little absorbed elsewhere. If you still have your uterus and take systemic estrogen, you also need a progestogen to protect the womb lining. The right choice depends on your health history and is made with a clinician.
The choices behind every HRT decision
- Systemic or local. Systemic HRT treats whole-body symptoms. Local vaginal estrogen treats dryness and urinary symptoms with very little absorbed elsewhere.
- Which route of estrogen. Through the skin (patch, gel, spray) or by tablet. The route changes the risk picture more than the dose does.
- Progestogen, if you have a uterus. Systemic estrogen is paired with a progestogen to protect the womb lining. After a hysterectomy, estrogen is usually given alone.
Side-by-side comparison
| Method | How it is taken | Mainly treats | Clot risk | Good to know |
|---|---|---|---|---|
| Skin patch | Adhesive patch changed once or twice a week | Whole-body symptoms (hot flashes, sleep, mood) | Not linked to the raised clot risk of tablets | Steady dose. Often preferred with clot risk factors, migraine or higher BMI. |
| Gel or spray | Applied to the skin daily | Whole-body symptoms | Same skin-route profile as patches | Flexible dosing. Needs drying time and care about transfer to others. |
| Tablet | Swallowed daily | Whole-body symptoms | Small increase in clot risk vs skin routes | Simple and familiar. Often avoided where clot risk is a concern. |
| Vaginal (local) | Cream, pessary or ring | Vaginal dryness and urinary symptoms (GSM) | Minimal absorption, minimal systemic effect | Can be used long term and alongside systemic HRT. Usually no progestogen needed. |
| Progestogen | Micronized progesterone, tablet or IUS | Protects the womb lining (if you have a uterus) | Route and type affect the overall profile | Paired with systemic estrogen. Not needed after hysterectomy. |
Simplified for comparison. Individual products, doses and risks vary.
How the delivery method changes the risk picture
The most practical difference between the routes is blood-clot risk. Estrogen taken as a tablet is processed by the liver first, which carries a small increase in the risk of venous clots. Estrogen absorbed through the skin skips that first pass, and at standard doses is not associated with that increased clot risk. This is why many guidelines suggest a skin route for women who have clot risk factors, migraine with aura, or a higher BMI. Local vaginal estrogen is a separate case: so little is absorbed that it is generally considered safe to use long term, including for many women who cannot or prefer not to use systemic HRT.
Choosing with your clinician
- Name your main symptoms first. Whole-body symptoms and local dryness are treated differently.
- Share your history: clots, migraine, blood pressure, breast health, and family history.
- Ask why a particular route is being suggested for you specifically.
- Factor in what you will actually keep using: a daily gel, a twice-weekly patch, or a tablet.
- Plan a review. Doses and forms are often adjusted after the first few months.
Common questions
- Which type of HRT is safest?
- There is no single safest type for everyone. For most women, estrogen delivered through the skin (a patch, gel or spray) is not linked to the increased blood-clot risk seen with estrogen tablets, so transdermal routes are often preferred if you have clot risk factors, migraine or a higher BMI. The right choice depends on your health history, symptoms and preferences, and is a decision to make with a clinician.
- What is the difference between systemic and local (vaginal) HRT?
- Systemic HRT (patches, gels, sprays and tablets) raises hormone levels throughout the body and treats whole-body symptoms such as hot flashes, night sweats, sleep and mood changes. Local vaginal estrogen (a cream, pessary or ring) acts mainly on the vaginal and urinary tissues to treat dryness, discomfort and recurrent urinary symptoms, with very little absorbed into the rest of the body.
- Do I need progesterone with estrogen?
- If you still have your uterus and take systemic estrogen, you also need a progestogen (such as micronized progesterone) to protect the womb lining. If you have had a hysterectomy, estrogen is usually given on its own. Local vaginal estrogen generally does not require a progestogen.
- Are patches better than tablets?
- Neither is universally better. Patches and other transdermal routes avoid the small increase in clot risk associated with oral estrogen and can suit people who prefer not to take a daily pill. Tablets are simple and familiar. The best route depends on your risk profile and what you will realistically use consistently.
- Where does testosterone fit in?
- Testosterone is sometimes added, off-label in many countries, mainly for persistent low sexual desire that has not improved with standard HRT. It is not a first-line treatment for hot flashes or mood, and it is prescribed and monitored by a clinician.
Take this further
Yellow does not prescribe or recommend a specific treatment. It helps you understand your options and find clinicians who work in this area.
Related reading
Sources
This article is for general information only and is not medical advice. Hormone therapy decisions depend on your individual health history. Please talk to a qualified clinician about what is right for you.