Menopause treatment in the UK is not a single product — it is a category with several delivery routes. Once a clinician has decided systemic HRT is appropriate, the next question is how the oestrogen enters the body. That decision affects clotting risk, side-effect profile, dose flexibility and how well the regimen fits into daily life.
This guide walks through oral tablets, transdermal patches, gel and spray, why the route matters clinically, and how the progestogen component fits in for women with a uterus.
The four delivery routes at a glance
The table below summarises the main differences UK clinicians consider when matching a patient to a route. It is a starting point for a consultation, not a self-selection tool.
| Route | How it works | Clot (VTE) risk vs oral | Dose flexibility | Common practical issues |
|---|---|---|---|---|
| Oral tablet | Swallowed daily; absorbed through the gut and processed by the liver first | Higher (first-pass effect on clotting factors) | Fixed daily strength | Least suitable for women with clot risk factors; simple to remember |
| Transdermal patch | Adhesive patch worn on skin; delivers oestrogen continuously for two doses per week | Lower — bypasses liver | Fixed strengths (25, 50, 75, 100 mcg) | Adhesion in warm weather; occasional skin reaction |
| Transdermal gel | Applied daily to arms/thighs; dries quickly and absorbs through skin | Lower — bypasses liver | Very flexible — adjusted by pumps or sachets | Application routine; drying time; transfer risk if not dry |
| Transdermal spray | Metered spray to the inner forearm daily | Lower — bypasses liver | Flexible — adjusted by spray count | Availability varies; brand supply can fluctuate |
Oral tablets — how they work and who suits them
Oral HRT was the original delivery format. A daily tablet contains an oestrogen (typically estradiol) and, if the woman has a uterus, either a separate progestogen or a fixed combination. The tablet is absorbed through the small intestine and passes through the liver before reaching the general circulation. This is called first-pass metabolism.
First-pass metabolism is not always harmful — for many women it is clinically fine — but it does change the way the liver produces clotting factors and other proteins. This is why oral oestrogen is associated with a small but measurable increase in the risk of venous thromboembolism (VTE, meaning deep vein thrombosis or pulmonary embolism) compared with transdermal routes.
Oral tablets can suit women who prefer a simple daily pill, have no additional clot risk factors and tolerate the regimen well. A common combined tablet is Utrogestan for the progestogen component alongside a separate oestrogen, or a fixed combination preparation.
Transdermal patches — how they work and who suits them
A transdermal oestrogen patch is a thin adhesive that releases oestrogen through intact skin at a steady rate over several days. Most patches are changed twice weekly. Some are oestrogen-only (paired with a separate progestogen), and some are combined — such as Evorel Conti, which contains both estradiol and a progestogen in a single patch for women no longer having periods.
Because the oestrogen enters the bloodstream through the skin, it reaches the general circulation without passing through the liver. That means the effect on clotting factors is smaller, which is the pharmacological basis for the observed lower VTE risk compared with oral routes.
Practical drawbacks are almost all cosmetic or logistical: patches occasionally lose adhesion, especially in warm humid weather, after swimming, or at the beach. A minority of women get local skin irritation. Rotating the application site — usually the buttock or lower back — usually resolves this. Patches are a common first choice when a UK clinician wants transdermal delivery with the simplest possible routine.
Topical gel and spray — how they work and who suits them
Gel and spray are also transdermal but applied daily. Oestrogel is a metered-pump oestrogen gel applied to the arms or thighs; other gel products come in single-dose sachets. Spray formulations deliver metered doses to the inner forearm.
The main clinical attraction of gel and spray is dose flexibility. Because the dose is set by the number of pumps or sprays, a clinician can titrate finely — adding half a pump, reducing one spray — to match a woman's symptoms without jumping between fixed patch strengths. This suits women who are dose-sensitive, who fall between standard patch strengths, or whose symptoms fluctuate.
Practical points to consider include the application routine (letting it dry fully before dressing), avoiding transfer to others (particularly small children), and the day-to-day discipline of remembering a daily application. As with patches, gel and spray bypass the liver and are associated with a lower VTE risk than oral HRT.
Why the delivery route matters — first-pass metabolism and clot risk
The clinical case for the transdermal routes is not about efficacy on menopausal symptoms — all four routes can effectively treat hot flushes, night sweats, sleep disturbance and other vasomotor symptoms when dosed appropriately. It is about the safety trade-offs on the way in.
NICE guidance for menopause recommends transdermal HRT as the first-line route for women at higher risk of venous thromboembolism — for example, those with a higher BMI, a history of clots, or other clot risk factors. It is also often preferred for women with certain migraine patterns and for those on medications that interact with liver enzymes.
For a woman with no additional clot risk factors, both oral and transdermal are reasonable — the absolute risk of clots on modern HRT remains small — and the choice comes down to preference, tolerance and dose fit. A related question people often ask is how long HRT takes to start working; the route does not usually change that timeline.
Progestogen: the same route, or different?
If you have a uterus and take systemic oestrogen, you need a progestogen too. Its job is to protect the lining of the womb (the endometrium) against overgrowth from unopposed oestrogen. There are three main options:
- Oral micronised progesterone — commonly Utrogestan capsules, taken either continuously (daily) or cyclically (for part of each month). Widely used and body-identical.
- Combined transdermal patch — an oestrogen-plus-progestogen patch that delivers both hormones through the skin in one product. Convenient if a woman prefers to keep everything transdermal.
- Mirena intrauterine system (IUS) — a levonorgestrel-releasing coil fitted by a clinician. It provides endometrial protection while also acting as contraception, and it changes the progestogen exposure profile compared with the other routes.
The progestogen route does not have to match the oestrogen route. A common UK regimen is transdermal oestrogen (patch or gel) plus oral micronised progesterone at night.
How UK clinicians pick a route for you
In a Farmeci consultation, the discussion usually covers:
- Personal and family medical history — particularly clots, breast cancer, cardiovascular disease and migraine with aura.
- Whether you still have periods, are perimenopausal, or are past menopause — this influences whether cyclical or continuous progestogen is appropriate, and which combined preparations fit.
- Preference and lifestyle — daily routine, exercise, skin sensitivity, ability to remember a daily application.
- Skin tolerance — a previous rash from patches steers a clinician toward gel or spray.
- Dose responsiveness — how well symptoms respond to a starting dose, whether fine adjustment is needed.
Route can be revisited over time. Women often start on one delivery route and move to another as their body changes, their preferences shift or availability of specific products changes. If you would like an overview of adjacent women's health topics, the Women's Health section covers hormonal contraception, cycle symptoms, sexual and vaginal health, and further HRT reading including emergency contraception for related contexts.