HRT patches, gel or tablets: what the route actually changes

Oestrogen in HRT reaches the body in one of two ways. Tablets are swallowed. Patches, gel and spray deliver it through the skin, which guidelines call transdermal. The question people ask most is whether the route matters, and the answer from the guidelines is: for some risks, clearly yes, and for most other things, not much.

This article describes what that guidance says. It is not advice about your own treatment, which is a conversation for you and the clinician who prescribes it.

The short version

The main documented difference is blood clots. NICE states that the risk of venous thromboembolism (a clot in a vein) is not increased with transdermal HRT, is increased with oral HRT, and is greater with oral than with transdermal HRT ¹. The NHS puts it plainly: patches, gel and spray do not increase the risk of blood clots, while tablets can, although the overall risk is still small ²³.

Stroke follows a similar pattern, with much smaller numbers. Most other outcomes, including the need for a progestogen if you have a womb, do not depend on the route.

The forms, side by side

The NHS lists the forms of HRT as tablets, patches, gel, spray, and vaginal rings, pessaries or cream ². Tablets are taken every day. Patches are changed every few days. Gel and spray are applied to the skin once a day ².

Vaginal oestrogen is a different thing. It treats local symptoms such as dryness, rather than symptoms throughout the body ². The rest of this article is about systemic HRT, the kind that reaches the bloodstream.

Doses are matched across forms. The British Menopause Society publishes an approximate equivalence table for clinicians: a low dose might be a 25 microgram patch, one pump of a common gel, or 0.5 mg of oral oestradiol ⁵. It notes the equivalents cannot be precise, because people absorb and break down oestrogen differently ⁵.

Blood clots

NICE's three statements on venous thromboembolism are the clearest route difference in the guideline ¹:

• risk is not increased with transdermal HRT
• risk is increased with oral HRT
• risk is greater with oral than with transdermal HRT

Because of this, NICE recommends that clinicians consider transdermal rather than oral HRT for people at increased risk of clots, including people with a body mass index over 30 ¹. For people at high risk, such as those with a strong family history of clots or an inherited clotting condition, it recommends considering referral to a haematologist before HRT ¹.

Stroke

NICE says stroke risk is unlikely to increase with combined HRT that uses transdermal oestrogen ¹. With oral oestrogen, stroke risk does increase, and the increase grows with higher doses, longer use, and older age at starting ¹.

The absolute numbers are small. In NICE's discussion aid, 3 in 1,000 women aged 50 to 54 who never take HRT have a stroke over five years, and the numbers are similar for women taking either form ⁴. The difference is too small to show in groups of 1,000. NICE notes that for oral oestrogen it is statistically significant, and for transdermal oestrogen it is not ⁴.

What the route does not change

Some risks do not move with the route.

• The womb lining. In people with a uterus, oestrogen on its own raises the risk of endometrial cancer whether it is taken orally or through the skin ¹. That is why a progestogen is needed with either route if you have a womb ². The guide on progestogens on this site covers this.
• Type 2 diabetes. NICE says HRT does not increase the risk of type 2 diabetes, and that this does not depend on route ¹.
• Ovarian cancer with oestrogen-only HRT. NICE says the very slight increase after five years of use applies to both routes ¹.

Side effects and switching

The British Menopause Society lists changing the route among the options for managing oestrogen side effects such as breast tenderness, bloating, nausea and headaches, alongside reducing the dose or changing the type ⁵. Whether that suits you is a decision for your prescriber.

Guidance in the US and Europe

In the US, The Menopause Society says the risks of hormone therapy differ depending on the type, dose, duration, route, timing of starting, and whether a progestogen is used ⁶. The FDA's 2026 label changes covered both systemic estrogen products and vaginal estrogen ⁷.

In Europe, the European Menopause and Andropause Society (EMAS) says treatment should be individualised to age, symptom severity, personal and family risk, other conditions and preference, rather than following a one-size-fits-all approach ⁸.

What is still uncertain

Guidelines say little about which form people find easier to live with. Daily gel, a patch changed twice a week, and a tablet each fit some routines better than others, and that is a fair thing to raise at an appointment.

Keeping a record

If you change route or dose, note the date. Symptoms, side effects and any bleeding in the weeks after a change are what a review looks at. Halcyon puts each change on the same timeline as your symptoms, if you would rather keep it on your phone than in a notebook.