Key takeaways
- Estrogen treats the symptoms. A progestogen is added only to protect the womb lining, so women who have had a hysterectomy usually need estrogen alone.
- Patches, gels and sprays (transdermal estrogen) at standard doses do not raise blood clot risk above baseline, while tablets do slightly, according to NICE.
- Sequential regimens suit women still having periods; continuous regimens suit women who are postmenopausal.
- In November 2025 the US FDA began removing the broad boxed warnings about heart disease, breast cancer and dementia from hormone therapy labels, while keeping the warning about womb cancer with estrogen alone in women who have a womb.
- Hormone therapy is a prescription decision after assessment, with a review at three months and then yearly.
What is actually in hormone therapy?
When I say "hormone therapy", many women imagine one strong tablet that does something dramatic to the body. It is not like that. Think of it as giving back, in a measured way, some of the youthful estrogen we had all our lives. There are two main parts.
Estrogen is the hormone that relieves hot flushes, night sweats, sleep disturbance linked to sweats, and many other symptoms. It also helps protect bone. The form most commonly used today is estradiol, which is chemically the same as the estrogen your ovaries made.
Progestogen is added for women who still have a womb. Estrogen on its own makes the womb lining grow, which raises the risk of womb (endometrial) cancer. A progestogen keeps the lining in check, like a gardener trimming the grass so it doesn't overgrow. Options include micronised progesterone (chemically the same as your own progesterone, taken as a capsule), synthetic progestogens in tablets or combined patches, and the hormonal coil (levonorgestrel intrauterine system), which also works as contraception.
Other options I may mention: - Vaginal estrogen: low-dose creams, tablets or rings for local dryness and bladder symptoms. It acts locally and, according to the NHS, does not need a progestogen even if you have a womb. It does not treat hot flushes. - Tibolone: a once-daily tablet that acts much like combined therapy with an added testosterone-like effect, for postmenopausal women only. - Testosterone: sometimes considered by specialists for low desire when estrogen alone has not helped. NICE notes this is off-label use.
Tablets, patches, gels or sprays: what is the difference?
| Form | How you use it | Points to know |
|---|---|---|
| Tablet | Once a day by mouth | Familiar and simple. NICE says oral estrogen carries a higher clot risk than skin forms, and a small increase in stroke risk |
| Patch | Stuck on the skin, changed every few days depending on the product | No added clot risk at standard doses. May not stick well in sweaty, humid weather, or may irritate the skin |
| Gel | Rubbed into the skin once a day | No added clot risk at standard doses. Needs a few minutes to dry |
| Spray | Sprayed on the inner arm once a day | No added clot risk at standard doses. Avoid bathing for about an hour afterwards |
| Vaginal estrogen | Cream, tablet, pessary or ring inside the vagina | For local symptoms only; very little reaches the bloodstream |
NICE advises considering transdermal estrogen (patch, gel or spray) for women at higher risk of clots, including those with a BMI over 30. For women with weight concerns or other clot risk factors, a skin form is a common discussion point. And yes, in a Mumbai monsoon, whether a patch will stay on is a very real question we discuss.
Sequential or continuous: which pattern suits you?
For women with a womb, the progestogen can be given in two patterns:
- Sequential (cyclical) therapy: estrogen every day, with progestogen added for 10 to 14 days of each month. You get a regular, usually lighter, monthly bleed. This suits women who are still having periods or whose periods stopped less than a year ago.
- Continuous combined therapy: estrogen and progestogen every day, aiming for no bleeding. This suits women who are postmenopausal. Irregular spotting is common in the first three months, and NICE advises reporting it at the three-month review, or promptly if it starts later.
Women without a womb take estrogen alone, with no bleeding.
What do "body-identical" and "bioidentical" really mean?
These words cause so much confusion, so let me be clear.
Body-identical usually means regulated, licensed medicines containing estradiol and micronised progesterone, which have the same chemical structure as your own hormones. I commonly use these. But "body-identical" describes the molecule, not a safety guarantee. Like all hormone therapy, they have benefits and risks that need to be discussed for your situation.
Compounded bioidentical hormones are custom mixtures, often creams or troches, made up by some pharmacies and often "dosed" by saliva or blood tests. The Menopause Society's 2022 position statement raises safety concerns about them, including limited regulation, inconsistent doses, impurities and a lack of safety and efficacy data. The Australasian Menopause Society notes that compounded products have been linked with womb cancer where the progestogen did not protect the lining. I do not recommend them.
What did the FDA change in November 2025?
On 10 November 2025, the US Department of Health and Human Services announced that the FDA was initiating removal of the broad boxed warnings on menopausal hormone therapy products. Companies are updating labels to remove references to risks of cardiovascular disease, breast cancer and probable dementia from the boxed warning. The FDA said it is not seeking to remove the boxed warning about endometrial cancer for systemic estrogen-alone products. The FDA's labelled recommendation is to start systemic hormone therapy within 10 years of menopause or before age 60, with timing and duration decided between doctor and patient.
The warnings dated back to interpretations of the Women's Health Initiative study around 2002, which was widely misread as showing hormone therapy was dangerous for all women. I have seen a whole generation of women suffer quietly because of that misreading. The European Menopause and Andropause Society welcomed the change but cautioned that removing a warning "does not imply that MHT is suitable for every woman", and that the goal is "appropriate prescribing, not maximal prescribing."
The point is: hormone therapy is now viewed more positively for suitable women, but the risks that exist, including a small increase in breast cancer risk with combined therapy and clot risk with tablets, still need an honest conversation. See Does hormone therapy cause breast cancer?
How long can you take it, and how is it reviewed?
- NICE recommends a review at three months to check how well it works and any side effects, then yearly.
- The Menopause Society says hormone therapy does not need to be routinely stopped at 60 or 65; continuing can be considered after evaluation if symptoms persist or for bone protection.
- When stopping, NICE says you can reduce gradually or stop at once. Gradual reduction may limit a short-term return of symptoms but makes no difference in the long term.
Who should not take hormone therapy?
Some women are advised against it or need specialist input, for example those with a history of breast cancer, certain clotting problems, active liver disease or unexplained vaginal bleeding. See Who should not take menopausal hormone therapy? For women who cannot take hormones, see Non-hormonal treatments for hot flushes.
How I approach this at Dr Tvacha
At Cocoon × Dr Tvacha in Thane West, I discuss hormone therapy only after a long consultation covering your symptoms, periods, personal and family history, blood pressure and only the tests your history needs. If you choose to start, the type, form and dose are explained in writing, with reviews at three months and then yearly. Ongoing hormone care under the Right Stop Programme is Rs 4,000 to 9,000 a month depending on your plan; see our women's health page.
Frequently asked questions
Which is better for me, a patch or a tablet?
Neither is better for everyone. NICE says patches, gels and sprays at standard doses do not increase clot risk above baseline, while tablets do slightly. Skin forms are often preferred for women with a higher clot risk, a BMI over 30, or certain other conditions. Some women prefer tablets for simplicity. I help you weigh this for your own body and routine.
Do I need progesterone if I have had a hysterectomy?
Usually not. The progestogen is there only to protect the womb lining, so if your womb has been removed, you generally take estrogen alone. There can be exceptions in certain conditions, so your gynaecologist will confirm what applies to you before you start anything.
Will hormone therapy make me bleed again?
Sequential therapy causes a monthly bleed, and that is expected. Continuous combined therapy aims for no bleeding, but irregular spotting is common in the first three months. Bleeding that starts after that, or is heavy, should be reported promptly. The NHS advises seeing a doctor if bleeding on hormone therapy continues beyond six months.
Is hormone therapy available in India?
Yes. Hormone therapy medicines, including estradiol and micronised progesterone, are prescribed in India, though not every form or strength is always available. I choose from what is reliably available and suits you. Please take hormone therapy only on a prescription after assessment, never bought over the counter or on a friend's advice.
Does hormone therapy delay menopause?
No. It does not stop or delay the underlying change in your ovaries. It replaces hormones to relieve symptoms. When you eventually stop, some women notice symptoms returning for a while, which is why stopping is planned with your doctor rather than done abruptly without advice.
Written by
Dr Anagha KarkhanisGynaecologist and Fertility Specialist · Reg. No. 2006/02/1187Leads midlife women's health at Cocoon × Dr Tvacha, Thane.
Sources
- Menopause: identification and management (NICE guideline NG23), recommendations
- Types of hormone replacement therapy (NHS)
- HHS advances women's health, removes misleading FDA warnings on hormone replacement therapy (HHS, 10 November 2025)
- FDA press announcement on hormone replacement therapy labelling (FDA)
- The Menopause Society 2022 hormone therapy position statement, press release
- EMAS statement on the FDA decision to remove boxed warnings from menopausal hormone therapy
This article is for general education and does not replace a consultation. Medicines and treatments are prescribed only after a doctor's assessment. Last reviewed 25 October 2026.