Types of HRT for Perimenopause: A Complete Guide
Understand every type of HRT available for perimenopause, from estrogen-only to combined, body-identical to synthetic, patches to gels and beyond.
Why HRT Type Matters
Hormone replacement therapy is not a single product. It is a broad category covering dozens of formulations, delivery methods, and hormone combinations. The type you use affects how hormones are absorbed, how your body metabolises them, and which side effects or risks apply. Understanding the options helps you have a more productive conversation with your prescriber and increases the chance of finding a regimen that works well for you.
Estrogen-Only vs Combined HRT
Estrogen is the primary hormone that relieves perimenopause symptoms. However, if you have a uterus, taking estrogen alone raises the risk of endometrial hyperplasia over time. Combined HRT pairs estrogen with a progestogen to protect the uterine lining. Women who have had a hysterectomy can safely use estrogen-only preparations. Combined HRT comes in two main patterns: sequential (cyclic) regimens, where progestogen is added for around 12 to 14 days per month and a withdrawal bleed usually occurs, and continuous combined regimens, where both hormones are taken every day and bleeding typically stops. Sequential is often preferred in early perimenopause when cycles are still irregular. Continuous combined suits those who are fully menopausal or postmenopausal.
Body-Identical vs Synthetic Hormones
Body-identical hormones have a molecular structure identical to the hormones your ovaries produce. Estradiol (the main estrogen used in most modern patches, gels, and sprays) is body-identical. Micronised progesterone (sold as Utrogestan) is body-identical progesterone. Synthetic progestogens such as norethisterone or medroxyprogesterone acetate behave differently in the body and carry a modestly higher breast cancer risk compared with micronised progesterone in current evidence. Most current clinical guidelines recommend body-identical estradiol plus micronised progesterone as the preferred choice, particularly for women with cardiovascular risk factors or those concerned about breast cancer risk. Compounded bioidentical hormones (from specialist pharmacies) are not the same thing and are not recommended by mainstream medical bodies because dosing is unregulated.
Delivery Methods: How Estrogen Reaches Your Body
Transdermal estrogen (patches, gels, sprays) bypasses the liver on first pass, which means it does not raise clotting factors the way oral tablets can. This makes transdermal routes the preferred option for women with a history of migraines, elevated blood pressure, or higher clotting risk. Patches are applied once or twice a week and suit those who prefer not to remember a daily dose. Gels are rubbed into the skin daily, usually on the inner arm or thigh, and offer dose flexibility. Sprays work similarly to gels. Oral tablets are convenient and effective but carry slightly higher venous thromboembolism risk compared with transdermal routes. Implants (pellets inserted under the skin) provide a steady hormone release for several months but are less common, harder to reverse, and not available everywhere. Vaginal estrogen (creams, pessaries, rings) acts locally and is used for urogenital symptoms rather than systemic relief.
Progestogen Options
If you use combined HRT, your progestogen choice matters. Micronised progesterone (Utrogestan) is taken orally or vaginally and is widely considered the safest progestogen for breast and cardiovascular health based on current evidence. It can also have a mild sedative effect, which some women find helpful for sleep when taken at night. Synthetic progestogens such as levonorgestrel, norethisterone, and dydrogesterone are used in many combined pills, patches, and intrauterine systems. The levonorgestrel-releasing IUS (Mirena) is an option for women who want the convenience of local uterine protection without systemic progestogen effects. Your prescriber can help weigh the options based on your personal history.
Testosterone as an Add-On
Testosterone is produced by the ovaries throughout a woman's life and declines during perimenopause along with estrogen. Low testosterone can contribute to fatigue, reduced libido, low motivation, and difficulty concentrating. Testosterone is not a licensed HRT product for women in most countries, but it is widely prescribed off-label using formulations intended for men (at around one-tenth of the male dose) or via compounded preparations where available. It is typically applied as a gel to the inner thigh. Evidence supports its use specifically for low libido in perimenopausal and postmenopausal women. It is generally considered alongside estrogen rather than instead of it. If you are curious about testosterone, bring it up with your prescriber and ask about local prescribing options.
Choosing With Your Prescriber
There is no single right answer when it comes to HRT type. The choice depends on your symptom profile, personal and family medical history, lifestyle, preferences, and uterus status. A prescriber experienced in menopause medicine will take all of this into account. It is reasonable to trial one formulation, reassess after three months, and adjust if needed. Some women try two or three approaches before finding what suits them. Tracking your symptoms, mood, and energy levels over time gives you and your prescriber useful data to guide decisions. The PeriPlan app lets you log symptoms and track patterns day by day, so you can arrive at consultations with a clear record rather than relying on memory.
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