What are the types and forms of HRT?

6 min read Clinically reviewed · September 28, 2026 Updated: October 27, 2026 PerimenopauseMenopausePostmenopause

Summary

"HRT" does not mean one medicine but a range of options that vary along several axes: which estrogen, which progestogen, by which route (tablet, skin, vaginal) and on which regimen (cyclical or continuous). Each of those choices changes both the effect and the risk profile; the biggest differences are that estrogen applied through the skin does not raise the risk of clots, and that hormones identical to the body's own (estradiol, micronized progesterone) have become the preferred choice. The word "bioidentical", meanwhile, blurs two different things: licensed, regulated medicines, and specially compounded mixtures with no evidence behind them. Guidelines support the first and do not recommend the second. Only your doctor decides which combination suits you.

What is happening?

Estrogen: which one, and by which route?

Types. Estradiol, the most widely used in systemic treatment today, is the same molecule the ovaries produce. The conjugated estrogens used in the WHI trial are a mixture of equine origin, and their use has declined. Estriol is a weak estrogen, found mainly in vaginal products.

Routes. The same hormone behaves differently in the body depending on how it is given:

By mouth (tablet): Processed on first pass through the liver. This can raise clotting factors and some carrier proteins, and it is where the increase in clot risk comes from.

Through the skin (gel, spray, patch): There is no first pass through the liver. Because it does not raise clot risk and is more neutral for blood pressure and triglycerides, it is preferred in conditions such as obesity, migraine, raised clot risk, hypertension or diabetes.

Vaginal (cream, pessary, ring): Acts only on the tissue of the vagina and lower urinary tract. Very little passes into the blood. It does not treat hot flashes. It is used for vaginal dryness, painful sex and recurrent urinary tract infections. A progestogen is generally not needed with this form.

Progestogen: why, which one, on what regimen?

Every woman who still has her womb must have a progestogen alongside systemic estrogen; otherwise the lining of the womb can thicken. The options:

Micronized progesterone: Structurally identical to the body's own progesterone. Usually taken at night, because it is mildly sedating.

Dydrogesterone: A derivative structurally close to progesterone.

Synthetic progestins: Older and more varied molecules (medroxyprogesterone acetate, used in WHI, is one of them).

Hormonal intrauterine device (levonorgestrel IUD): Delivers the progestogen directly into the womb. It both protects the lining of the womb and prevents pregnancy, which makes it a practical option in perimenopause while contraception is still needed.

There are two kinds of regimen, and they map exactly onto regimen tracking in Lumia:

Cyclical regimen: Estrogen every day, progestogen for a set part of the month; when the progestogen stops, a period-like withdrawal bleed follows. Preferred in perimenopause and in the first year after the final period, because the womb is still keeping its own bleeding pattern.

Continuous combined regimen: Estrogen and progestogen taken together every day, aiming for no bleeding at all. Usually started at least 12 months after the final period. Spotting can occur in the first months; bleeding that continues beyond 6 months should be assessed.

Women whose womb has been removed are usually given estrogen alone; there are exceptions, such as a history of endometriosis.

Tibolone: a separate option

Tibolone is a synthetic medicine that combines estrogen-like, progestogen-like and androgen-like effects in a single molecule. It does not need an additional progestogen in a woman with a womb, and like a continuous combined regimen it is started at least 12 months after the final period. It is effective for hot flashes, vaginal symptoms and bone; a positive effect on sexual desire has also been reported. Breast cancer risk appears lower than with an estrogen–progestogen combination, though it is not zero; it is not recommended over 60 because of stroke risk ¹ ⁸. It has long been available in Türkiye; whether it suits you is your doctor's decision.

What does "bioidentical" mean?

The word is used for two different things, and the difference matters:

Licensed hormones identical to the body's own (estradiol, micronized progesterone): produced to a standard, with dose and purity regulated, and supported by clinical trials. These are the options guidelines recommend first today.

Specially compounded "bioidentical" mixtures: products mixed to order in a pharmacy, often dosed against a saliva or blood "hormone profile". They are not licensed, the consistency of their contents is not regulated, and there is no evidence of their effectiveness or safety.

What do we know?

The skin route does not raise clot risk: In an observational analysis covering some 80,000 cases, oral estrogen increased clot risk while estrogen applied through the skin did not ³. NICE recommends the skin route for women at higher clot risk ².

The type of progestogen may affect breast risk: In the French E3N cohort, women using micronized progesterone or dydrogesterone alongside estrogen had a lower risk of breast cancer than those using synthetic progestins ⁵. The 2019 meta-analysis likewise showed the increase to be greater on a continuous combined regimen than on a cyclical one, with the lowest — no increase at all — for vaginal estrogen ⁴. These data are observational; guidelines describe micronized progesterone as "probably more favorable" without claiming definite superiority ¹.

Vaginal estrogen is safe at low doses: Very little passes into the blood; it does not thicken the lining of the womb and needs no extra monitoring in long-term use. Adding a progestogen is not routinely recommended with this form ⁷.

Compounded mixtures are not recommended: A comprehensive review by the US National Academies reported that there is insufficient evidence for the effectiveness and safety of these products, that dosing is inconsistent, and that dosing based on saliva hormone testing has no scientific basis ⁶. The Menopause Society and NICE recommend against using them where a licensed alternative exists ¹ ².

Combined products and the choice of regimen are individual: There are patches and tablets that combine estrogen and progestogen in one product; giving them separately makes it easier to adjust the doses independently. Which is appropriate depends on age, stage, your preference about bleeding, and other conditions ¹.

Availability in Türkiye: Tablets, skin gels, patches, vaginal forms and tibolone are all options in use in Türkiye. Which products are actually stocked in pharmacies, the prescribing conditions and reimbursement status change over time, so they are not listed here. Ask your doctor and your pharmacist for the current position.

What does this give you?

Understanding your doctor's questions: "Tablet or gel?", "do you still have your womb?", "when was your last period?" are not random; each one settles one of the axes above.

Setting up your regimen record correctly: When you enter your regimen, record estrogen and progestogen as separate medicines, each with its own time, and mark the progestogen as "every day" or "certain days of the cycle" exactly as your doctor has written it. Lumia only turns this into a calendar and reminders; it does not suggest a regimen or a dose.

Questioning the words "natural" and "bioidentical": These words appear often in marketing language. The question to ask is simple: is this a licensed medicine, or a specially compounded mixture?

If your symptoms are only vaginal, systemic treatment isn't essential: Vaginal estrogen on its own is an effective option for these symptoms, without most of the systemic risks.

When to see a doctor?

Bleeding on a continuous combined regimen that continues beyond 6 months, or that starts again after a period with none.

Irregular or heavy bleeding outside the expected withdrawal bleed on a cyclical regimen.

Pain and swelling in one leg; sudden chest pain or breathlessness — these need urgent assessment.

A new lump in the breast, dimpling of the skin, discharge from the nipple.

A widespread skin reaction that does not settle where a patch or gel is applied.

These signs should be assessed without delay.

Sources

The Menopause Society. The 2022 Hormone Therapy Position Statement. Menopause. 2022;29(7):767-794.
NICE. Menopause: identification and management (NG23). 2015; updated November 2024.
Vinogradova Y, et al. Use of hormone replacement therapy and risk of venous thromboembolism. BMJ. 2019;364:k4810.
Collaborative Group on Hormonal Factors in Breast Cancer. Type and timing of menopausal hormone therapy and breast cancer risk. Lancet. 2019;394(10204):1159-1168.
Fournier A, et al. Unequal risks for breast cancer associated with different hormone replacement therapies. Breast Cancer Res Treat. 2008;107(1):103-111.
National Academies of Sciences, Engineering, and Medicine. The Clinical Utility of Compounded Bioidentical Hormone Therapy. 2020.
The Menopause Society. The 2020 Genitourinary Syndrome of Menopause Position Statement. Menopause. 2020;27(9):976-992.
Panay N, et al. International Menopause Society (IMS) recommendations and key messages on women's midlife health and menopause. Climacteric. 2025;28(6):634-656.

What you can ask your doctor

Are tablets or application through the skin more suitable for me, and why?
Since I still have my womb, which type of progestogen and which regimen (cyclical or continuous) are you considering?
If my symptoms are only vaginal, would vaginal estrogen be enough instead of systemic treatment?
Is the product I'll be using a licensed medicine, or a specially compounded mixture?

This content is for information only; it does not replace medical advice, diagnosis or treatment. The type of hormone, the route, the regimen and the dose are decided only by your doctor. Lumia does not recommend medicines, doses or brands.

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