HRT Routes and Doses Explained
A map of how sex hormones are actually delivered: patch, gel, oral, vaginal, injection, and pellet. Route changes clotting risk, convenience, and how fast you can stop—often more than the word bioidentical does.
Overview
HRT routes and doses are how you read a clinic menu without treating every cream as equivalent. The hormone (estradiol, progesterone, testosterone) is one decision. Skin vs gut vs muscle vs implant is another. First-pass liver metabolism, transfer to a partner, and whether you can stop this week all hang on the route.
The usual map
Transdermal patch / gel / spray: estradiol or testosterone through skin. Avoids some oral first-pass effects. Transfer risk with gels (kids, partners). Patches can irritate.
Oral: micronized progesterone at night is standard. Oral estrogen has more hepatic first-pass and a higher VTE signal in observational data than transdermal estradiol.
Vaginal: low-dose estrogen for genitourinary symptoms; not a hot-flash patch.
Injection: testosterone cypionate/enanthate on a weekly-ish schedule; estradiol injections exist but are less common in U.S. menopause care.
Pellet: months of drug, poor off-switch. See hormone pellets.
Dose is not a personality type
“Optimization” numbers on a handout are not a license to run testosterone to the top of a male range in everyone. Lowest effective dose for the indication is still the adult sentence. Compounded milligram claims only matter if the pharmacy is real and the indication is real. Saliva kits are a weak way to titrate systemic HRT.
Benefits
Lets you match clotting risk, convenience, and reversibility
Stops mixing vaginal estrogen with systemic HRT
Explains why gels transfer and pellets do not titrate
Helps you compare FDA-labeled products with compounded creams
Same hormones; different pharmacokinetics
The Procedure
1
Name the hormone and the job
2
Prefer labeled products when they fit
3
Use compounding for a reason
4
Plan the off-ramp
Preparation
Ask the clinic for the exact product name, milligrams, and whether it is FDA-approved or compounded. Bring clot/cancer history before you pick oral estrogen.
Recovery & Aftercare
Gels: dry before dressing; avoid skin-to-skin at the application site. Patches: rotate skin. Injections: site rotation. Pellets: incision care.
Risks & Considerations
Wrong route for the job (vaginal estrogen for hot flashes; unopposed estrogen cream with a uterus; gel transfer to a child; pellet overdose). Compounding errors and under-protected endometrium.
Frequently Asked Questions
References
[1]
NAMS 2022 hormone therapy position statement (Menopause, 2022).
https://doi.org/10.1097/GME.0000000000002028[2]
Canonico M. et al. Transdermal vs oral HRT and VTE (BMJ, 2008).
https://doi.org/10.1136/bmj.39510.537191.BE[3]
Bhasin S. et al. Endocrine Society testosterone guideline (J Clin Endocrinol Metab, 2018).
https://doi.org/10.1210/jc.2018-00229[4]
ACOG. Compounded bioidentical menopausal hormone therapy.
https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2012/08/compounded-bioidentical-menopausal-hormone-therapy
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