When you consider hormone therapy for your menopausal symptoms, the important question is not only if you should take hormones, but also the type of administration. Different methods of application mean a different set of benefits and risks too, but all forms of application have the same positive effects on menopausal symptoms.
Oral administration – tablet
Oral therapy, or taking hormones in the form of pills, has especially beneficial effects in cases when a woman has too many male hormones (androgens) in her blood. This condition is called hyperandrogenemia, and its main symptom is increased hair growth. Oral administration has further slight advantages, such as helping in the reduction of abdominal fat, improving insulin and cholesterol metabolism, and perhaps even increasing the body’s protection against neurological diseases. On the other hand, oral hormone therapy increases the risk of thrombosis.
It is important to note that oral estrogen increases CRP (C-reactive protein) and triglyceride levels in the body, which may increase the risk of cardiovascular diseases. Oral estrogen also increases SHBG and reduces testosterone levels, leading to decreased libido.
Oral estrogens have slightly less reliable absorption than transdermal estrogen. There is also less flexibility if there is a need for altering the dose. In comparison with transdermal estrogen, there are also more contraindications, such as obesity, diabetes, gallbladder disease, migraine, and so on.
Transdermal application – plaster, gel, or spray
The increased risk of thrombosis can be significantly reduced by transdermal estrogen therapy, where the hormone is applied through the skin. Transdermal application is a closer simulation of natural estrogen secretion than oral dosing. By taking hormones this way, they bypass the liver, making the hormone load on the organ significantly lower. Taking hormones in the forms of patches, sprays or gels significantly reduces the risk of thrombosis even if the patient is overweight. Transdermal hormones are also more effective in reducing the risk of stroke than oral ones. This is probably because this type of application is easy on blood pressure.
Patches usually stick well and are easy to use, users can swim, shower, bathe and swim with them on. They provide a constant level, so they can be better for women with migraines. In addition, patients can use more than one, which is useful for women with early menopause or primary ovarian insufficiency (POI), when higher doses are needed. On the other hand, some women do not like to have something stuck to their skin, and they can lead to local irritation. Sometimes they do not stick well or they crinkle, and some women find they have high absorption in hot climates.
With gels it is easy to alter the dose so women have more control. They usually absorb really easily and can be used with patches to ‘top up’ the dose. Women with cyclical symptoms (including PMS) can use more on days with worse symptoms. However, their dosing may be less precise compared to other topical treatments, and young women need higher doses and large quantities. Application is harder to remember as it is needed once or twice a day, and sachets can be hard to open.
It is very easy to alter the dose of sprays, and they absorb really easily. It forms a fast drying, non-irritating and invisible film onto the skin from which the drug can be slowly absorbed into the systemic circulation. This can provide stable blood estrogen levels.
Transdermal application has little or no effect on clotting factors, lipoprotein, hepatic enzymes, libido. Available data suggests it results in little to no increase in thromboembolic events, while it shows clinical efficacy for hot flashes at doses considerably lower than with oral estrogens.
Local administration
For those suffering predominantly from vaginal symptoms such as vaginal dryness, irritation, urinary tract infections and consequent sexual complaints, intravaginal administration of hormones can be the most optimal way to benefit from HRT. These products often need to be given in the long-term to continue to improve symptoms.
Vaginal estrogen is safe to give with HRT, and about 20% of women need both. It can be applied via pessaries, cream or vaginal rings. The dose of vaginal estrogen is very low: using 10 mcg estrogen pessaries regularly for one year is equivalent to just one 1 mg estradiol HRT tablet. Women who have had breast cancer (except those taking aromatase inhibitors) can still safely use and benefit from vaginally applied estrogen. Many women using vaginal estrogen should also be recommended to use vaginal moisturizers and lubricants too.
Individual therapy
Every woman’s body is different, so hormone replacement therapy should follow doctor's recommendations after thorough consultation and testing. Only then can the exact method of administration be determined to achieve the best results.