Types of HRT Explained: How to Choose the Best Option for Your Body

Key Takeaways: 

• Different types of HRT include systemic, local (vaginal), and bioidentical options 

• HRT can be taken in several ways, including pills, patches, gels, creams, and vaginal rings

• Treatment may be cyclic or continuous, depending on where you are in your journey

Menopause isn’t a single moment — it’s a transition that typically spans several years. As your hormone levels shift, you might notice hot flashes, sleep problems, mood changes, and vaginal dryness. 

Hormone replacement therapy (HRT) is one of the most effective ways to manage these symptoms. It works by replenishing the hormones your body is making less of, helping you feel more balanced. 

HRT comes in many forms, including pills, patches, creams, and vaginal rings. The best choice depends on your symptoms, health, and what feels right for you. That’s why it’s helpful to know your options.

In this guide, we’ll cover the types of hormone replacement therapy, how they work, who they’re best for, and what to know about potential risks and side effects.

Most women reach menopause between the ages of 45 and 55. You’ve officially reached menopause when you’ve gone 12 months without a period. But hormone levels begin to decline well before then, during perimenopause. The second half of perimenopause, which is the period of time leading up to menopause, is when most women begin to experience symptoms of low estrogen. 

Hormone replacement therapy works by replacing the hormones your body is making less of, estrogen and progesterone. Let’s take a closer look.

Estrogen

Estrogen is a reproductive hormone that does much more than simply supporting reproduction. It contributes to a variety of systems and can affect your:

• Mood

• Cognition

• Vaginal and urinary health 

• Sex drive

• Bone density

• Skin elasticity

• Heart health

The most common type of estrogen used in HRT is estradiol — the same form your body makes most during your reproductive years. Taking estradiol helps ease symptoms of low estrogen, including:

• Hot flashes and night sweats

• Vaginal dryness and discomfort

• Urinary problems

• Mood shifts

• Sleep disturbances 

Progesterone

Progesterone helps prepare the body for pregnancy and supports early pregnancy. It also plays a role in mood and sleep. 

During perimenopause and menopause, progesterone may drop faster than estrogen. Low progesterone can trigger anxiety, mood swings, heavy menstrual bleeding, and hot flashes.

If you still have a uterus, your healthcare provider will likely add progesterone to your hormone replacement treatment. This is because taking estrogen alone can cause the uterine lining to thicken, which may increase your risk of uterine cancer. 

No method is “best” for everyone — the right type of HRT for you depends on your symptoms, health history, lifestyle, and personal preferences. 

Types of HRT: Pros and Cons

There are several types of HRT and many different ways to administer it. Before we go into more detail, let’s take a quick look at your options in a side-by-side comparison: 

Systemic HRT sends hormones through your bloodstream to ease widespread menopause symptoms like hot flashes and mood swings. It comes as pills, patches, sprays, gels, and more. 

It can include estrogen alone (usually for people who’ve had a hysterectomy) or a combination of estrogen and progestogen (for those who still have a uterus).

Combined HRT Pills and Patches

Combined HRT contains a mix of estrogen and a progestogen (either natural progesterone or synthetic progestin). This gives you the symptom-fighting power of estrogen and the protective effects of progesterone all in one go. 

When it comes to choosing between the pill and the patch, much of it comes down to personal preference. If you have trouble remembering to take daily medications, the patch (changed weekly) might be a better option for you. If you already take daily medications, then adding one more into the mix might be easiest. 

Patches might be a better option than pills if you have a higher-than-average risk of blood clots or if you tend to have stomach issues.

Estrogen Pills

Your provider might prescribe estrogen-only oral HRT if you’ve had a hysterectomy.  You can also use estrogen-only pills if you have a progestin IUD or take oral progesterone. You take these oral tablets daily. 

Estrogen Gels or Sprays

Estrogen sprays and gels are topical treatments applied daily to the skin. The estrogen is absorbed into your bloodstream the same way it is with pills and patches. Gels and sprays tend to be popular with people who don’t like pills. 

If you have a uterus, you’ll use estrogen gels and sprays alongside a progesterone treatment, such as a pill or IUD.

IUD (Hormonal)

An intrauterine device (IUD) is a small coil that a doctor places in your uterus. It releases levonorgestrel, a synthetic progestin. It protects from pregnancy for up to 8 years. But for endometrial protection with HRT, it should be changed every 5 years. You can use it to protect your uterine lining during estrogen therapy. An IUD can also double as a form of birth control during perimenopause.

Local HRT targets vaginal and urinary symptoms — like dryness, itching, pain, and recurrent UTIs — without significantly affecting the rest of your body.

It delivers a low dose of estrogen directly to the vaginal tissue, with minimal absorption into the bloodstream. Because it doesn’t travel throughout the body, low-dose vaginal estrogen doesn’t treat full-body symptoms like hot flashes and mood swings.

This type of HRT is a great option if you're mainly dealing with vaginal or urinary symptoms. Another plus: You can use it long-term, even well into the postmenopausal phase of life.

Forms of Vaginal HRT

Local vaginal estrogen therapy comes in several forms, including:

• Vaginal creams. Applied directly inside the vagina using an applicator. The cream can be applied daily or several times per week. 

• Vaginal tablets. Small, dissolvable tablets inserted into the vagina with an applicator. Typically used daily for a while and then less often. 

• Vaginal rings. A soft, flexible ring placed inside the vagina that releases a slow, steady dose of estrogen over the course of three months.  

• Suppositories and capsules. Soft, solid formulations inserted into the vagina. 

3. Bioidentical Hormones

There is a lot of confusion around bioidentical hormones. Bioidentical hormones are chemically identical to your body’s hormones. Because they’re derived from plant-based sources, people often think they’re more natural and subsequently safer than traditional therapies. But research has not found this to be true. 

Estradiol, which is the standard form of estrogen found in HRT, is a bioidentical hormone. Its molecular structure is identical to the estradiol naturally produced in the body. It is FDA-approved and available in pills, patches, gels, and sprays. 

Micronized progesterone is an example of a bioidentical progestogen. Traditional HRT includes progestin, a synthetic progestogen. Some women say micronized progesterone causes fewer side effects than synthetic progestins, but research has yet to confirm these claims. 

Bioidentical options are available as both FDA-approved products and custom-compounded formulas.

Once you've chosen the type of HRT and how to take it, your healthcare provider will also recommend a treatment routine — meaning how often and in what pattern you should take the hormones.

The two main options are sequential (cyclic) and continuous.

Sequential Combined HRT

Also called cyclical combined HRT, your provider might suggest this routine if you're perimenopausal (still having periods, even if irregular). It mimics a natural menstrual cycle by delivering:

• Estrogen every day, and

• Progestogen for part of the month (usually 10 to 14 days)

This typically results in a monthly withdrawal bleed, similar to a light period. It might be an option if you haven’t yet reached menopause but need symptom relief.

Continuous Combined HRT

Healthcare professionals usually prescribe continuous combined HRT to people who are postmenopausal (12 or more months without a period). It involves taking both estrogen and progestogen every day, without a break.

If HRT isn’t right for you, there are other ways to manage symptoms without using hormones. These include:

• Antidepressants. SSRIs and SNRIs can ease hot flashes and support mood stability.

• Gabapentin. It may reduce hot flashes, as can clonidine and fezolinetant.

• Oxybutynin. This can help treat overactive bladder and may also improve hot flashes.

• Ospemifene. A selective estrogen receptor modulator (SERM) that treats painful sex due to vaginal thinning.

• Vaginal lubricants. These can help relieve dryness and discomfort.

• Complementary therapies. Acupuncture, herbal remedies, and supplements like black cohosh may also provide some relief.

Lifestyle changes can also support symptom relief. Eating balanced meals and staying active benefits your bones, mood, and sleep. Prioritizing good sleep habits and managing stress through mindfulness or therapy can also positively affect your well-being.

Hormone replacement therapy (HRT) can effectively relieve a wide range of menopausal symptoms, from hot flashes to mood changes and vaginal dryness. Let’s recap what we know:

• The different types of HRT are systemic and local. Choosing the right one depends on your symptoms, medical history, and goals.

• HRT also comes in many forms. These include pills, patches, gels, sprays, vaginal rings, and more, each with its own pros and cons.

• Treatment routines (like sequential vs. continuous) can be tailored to your stage of menopause. Your provider can help you decide which path is right for you.

There’s no single “right” way to navigate menopause. The type of hormone therapy you choose will depend on a variety of factors. Talk to a trusted healthcare provider about your HRT options.