Patches, Gels, Tablets, Vaginal, Pellets. Choosing How to Take MHT.

MHT can be taken in several forms. As a tablet, a patch, a gel, a spray, or a vaginal preparation. The hormone may be the same. The way it gets into your body is not.

The route matters more than most women are told.

Two pieces of language are worth defining first, because they are used everywhere and rarely explained.

Systemic MHT means hormone therapy that enters your bloodstream and travels around your body. It treats whole-body symptoms like hot flushes, night sweats, sleep changes, mood and joint pain. Systemic MHT comes in two forms. Oral, which is taken as a tablet and absorbed through the gut. Or transdermal, which means through the skin, taken as a patch, gel or spray.

Local MHT means hormone therapy applied directly to the vaginal area, treating symptoms in the vagina, vulva, urethra and bladder, with very little absorbed into the rest of the body. Local vaginal oestrogen is its own category, serves its own purpose, and is genuinely under-used in Australia.

This blog walks through each option, what it does, what is available in Australia, and what to ask your GP.

Why does the route matter so much?

Oestrogen taken as an oral tablet is absorbed through the gut and travels straight to the liver before reaching the rest of the body. This is called first-pass metabolism. As the oestrogen passes through the liver, the liver responds by producing more of the proteins involved in blood clotting. The clinical consequence is a small but measurable increase in the risk of venous thromboembolism (blood clots, including deep vein thrombosis and pulmonary embolism) [1].

The risk increase is largest for women who carry an additional risk factor. These include personal or family history of clotting, obesity, smoking, immobility, and inherited thrombophilias such as Factor V Leiden, one of the most common inherited clotting disorders. For a woman with one of these risk factors, the difference between oral and transdermal oestrogen is not theoretical.

Oestrogen absorbed through the skin from a patch, gel or spray bypasses the digestive tract and the liver. It enters the bloodstream directly and does not activate liver clotting factors in the same way. The current evidence, supported by AMS and Jean Hailes, is that transdermal oestrogen at standard doses does not appear to increase the risk of blood clots compared to women not on MHT [1,2].

Transdermal oestrogen is the modern Australian preference for most women starting MHT, and a current Australian GP discussion about MHT generally starts with transdermal. It is particularly preferred for women with clotting risk factors, women with migraines (where oral oestrogen can worsen migraine in some cases), and women over sixty considering MHT initiation. Oral oestrogen still has a role for women without those risk factors, and women already on oral MHT who are doing well do not need to switch.

What does transdermal MHT look like in Australia?

The TGA-approved transdermal options available in Australia include:

- Patches. Estradot and Estraderm are the two main brand options, both available in doses from 25 to 100 micrograms, changed twice a week.  

- Gels. Estrogel (a pump dispenser) and Sandrena (single-use sachets), applied daily. The gel is the option that offers the most adaptability if the dose needs adjusting up or down.  

- Sprays. Lenzetto, applied daily to the inner forearm.

A few practical notes

Patches. Apply to clean, dry skin on the lower abdomen or upper buttock. Avoid the breast area. Rotate the application site each time you change the patch, so the same patch of skin is not used twice in a row. Apply after a shower, ideally before exercising or putting on moisturiser, and press the patch firmly for around 30 seconds to help adhesion. If the patch lifts at the edges, a piece of paper tape over the top is acceptable.

Gels and sprays. These are not rubbed in like a moisturiser. The gel or spray is applied across clean, dry skin, usually inner thigh or upper arm, and left to dry and absorb on its own. Wait at least one hour before applying moisturiser, sunscreen, or anything else to the same area, because products applied near the application site can affect absorption [3].

Dose adjustment. Transdermal MHT is genuinely flexible. If symptoms are not well controlled, the dose can be increased. If side effects occur, it can be reduced. This must be discussed with your GP. Self-adjusting your dose based on social media advice is not safe and could put your health at risk.

When is oral MHT still appropriate?

Oral oestradiol, most commonly Progynova, is the tablet form. It is taken daily, and remains appropriate for women without specific risk factors for blood clots and for women who prefer the simplicity of a tablet.

Combined oral preparations, tablets containing both oestrogen and a synthetic progestogen, are also still available and prescribed. The current Australian preference for women starting MHT today is generally separate transdermal oestrogen plus oral micronised progesterone (Prometrium) at night.

What is vaginal oestrogen, and how is it different?

Vaginal oestrogen is often a separate conversation to systemic MHT. It is also one of the most under-used treatments in midlife women's health.

Genitourinary syndrome of menopause (GSM) is the umbrella term for the cluster of symptoms caused by oestrogen decline in the vaginal, vulvar, urethral and bladder tissue. It includes vaginal dryness, painful sex, urinary urgency, and recurrent urinary tract infections. Up to 84 per cent of postmenopausal women experience symptoms of GSM, and only a small minority receive treatment [4].

GSM is progressive. Without treatment, it gets worse over time, not better [4]. This is one of the reasons vaginal oestrogen has a role even in women whose symptoms are mild today, because starting earlier prevents progression to more severe vaginal and urinary changes.

Local vaginal oestrogen treats this directly. Available in Australia as:

- Vagifem. Small vaginal pessaries inserted with an applicator.  

- Ovestin. Available as both vaginal cream (with a measured applicator) and pessary.

Vaginal oestrogen has minimal systemic absorption, which means very little reaches the bloodstream. The GSM Position Statement summarises that vaginal hormones can be safely used in the long term, alongside systemic HRT, and women can receive systemic and local oestrogen concomitantly [4].

Vaginal oestrogen can be used in three different ways:

1. On its own, when vaginal or urinary symptoms are the only concern.  

2. Alongside systemic MHT, when both vaginal and whole-body symptoms are present. Around 10 to 25 per cent of women on systemic HRT continue to have urogenital symptoms, and adding local vaginal oestrogen alongside the systemic treatment is what those women need [4].  

3. As an option for women who cannot or choose not to take systemic MHT, including many breast cancer survivors. Recent observational data has not demonstrated an increased risk of breast cancer recurrence or death in women using vaginal oestrogen, including those treated with tamoxifen [4,5]. This is a specialist conversation, but it is a conversation that can be had.

Vaginal oestrogen and recurrent UTI

Recurrent urinary tract infections become more common with age, partly because of the changes in vaginal and urethral tissue caused by oestrogen decline. Vaginal oestrogen restores those tissues and is associated with a meaningful reduction in UTI frequency. A Cochrane review of postmenopausal women found that oestrogens were effective in preventing recurrent UTI compared to placebo [6]. The GSM Position Statement is direct on this: "Vaginal oestrogen use is also associated with reduced urinary symptoms and a decreased incidence of urinary tract infections" [4].

For women caught in a cycle of repeated UTIs and repeated antibiotic courses, vaginal oestrogen is often the missing piece of the picture, and is increasingly recommended in primary care as a way to break that cycle.

What about hormone pellets?

Hormone pellets are small implants, typically the size of a grain of rice, inserted under the skin by a clinician. They release hormones slowly over several months.

Pellets are widely promoted in the United States and other international menopause practices, sometimes as a bioidentical or natural option. They are not a mainstream Australian option. They are not TGA-approved as standard MHT. Most current Australian menopause specialists will not start a woman on them.

The clinical reasons cited for caution include variable and supraphysiological dosing (often well above pre-menopausal physiological levels), no way to adjust the dose once implanted, and lack of regulatory standardisation. The 2020 National Academies of Sciences review of compounded bioidentical hormone therapy concluded there is insufficient evidence to support the overall clinical utility of compounded products, citing the lack of standardisation, the risk of overdosing or underdosing, and the absence of long-term safety data [7].

How does progesterone get delivered?

If you have a uterus and are on systemic oestrogen, you need progesterone.

The Australian first-line is micronised progesterone, Prometrium, taken as an oral capsule at night. The night-time timing matters because micronised progesterone can have a sedating effect via its allopregnanolone metabolite, which is discussed in more detail in the progesterone blog in this series. For most women this is a benefit. Taken in the morning it can cause daytime drowsiness.

The other progesterone delivery option is the Mirena IUD, a hormonal intrauterine device that releases a small amount of levonorgestrel (a synthetic progestogen) directly into the uterus. The Mirena was originally a contraceptive and is now also approved as a progesterone option in MHT [8]. It provides endometrial protection for around five years and may be a good option for women who do not tolerate oral progesterone, women still needing contraception in late perimenopause, or women with heavy bleeding.

In simple terms

- The route changes the safety profile, particularly around blood clot risk. This matters most for women with clotting risk factors, including inherited thrombophilias such as Factor V Leiden.  

- Transdermal (patch, gel or spray) is the modern Australian preference for most women starting MHT. Oral is still appropriate for women without clotting risk factors, and women already on oral MHT who are doing well do not need to switch.  

- Vaginal oestrogen is genuinely under-used. It is one of the most evidence-based treatments for recurrent UTI in postmenopausal women, and can be used alone, alongside systemic MHT, or by women who cannot or choose not to take systemic MHT.  

- Pellets are not standard MHT in Australia.  

- For women with a uterus, micronised progesterone (Prometrium) at night is the body-identical first-line. The Mirena IUD is an alternative.

Want the complete picture?

There are three free resources to take this further.

Audio guide on MHT delivery methods. A 10-minute audio overview in plain language. menopausehub.com.au/delivery-audio

MHT Application Guide. Step-by-step instructions for patches, gels and sprays. menopausehub.com.au/links

Complete Guide. The full plain-language guide. menopausehub.com.au/links (

The end of the series

This is the last blog in the MHT series.

Across the six blogs, we have covered terminology (HRT vs MHT), the WHI study and how its results were communicated, the breast cancer evidence, the difference between body-identical, bioidentical, synthetic and compounded preparations, the conversation about progesterone after a hysterectomy, and how MHT is actually delivered.

Together they form a foundation for an informed conversation with your GP. A way to open that conversation, and a way to keep it going.

This information is educational only and does not constitute personal medical advice. Always consult a qualified health professional about your individual circumstances.

© 2026 Menopause Hub | Anna Pattison | Former Registered Nurse, Clinical Myotherapist, Menopause Mentor | menopausehub.com.au

CITATIONS

[1] Vinogradova, Y., et al. (2019). Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ, 364:k4810.

[2] Australasian Menopause Society. Information Sheet — Risks and Benefits of MHT. menopause.org.au

[3] Davis, S.R., Magraith, K. (2023). Practitioner's Toolkit for the Management of the Menopause. Medical Journal of Australia.

[4] Newson, L., Crockett, C., Phipps, C., et al. (2024). Position Statement for Management of Genitourinary Syndrome of the Menopause (GSM). Newson Health.

[5] Crandall, C.J., Diamant, A., Santoro, N. (2020). Safety of vaginal estrogens: a systematic review. Menopause, 27(3), 339-360.

[6] Perrotta, C., Aznar, M., Mejia, R., Albert, X., Ng, C.W. (2008). Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database of Systematic Reviews, (2), CD005131.

[7] MacArthur, R.B., Mattison, D., Parker, R.M. (2022). Compounded bioidentical hormone products, a path forward. Journal of the American Pharmacists Association, 62(1), 42-48. (Drawing on the National Academies of Sciences 2020 review.)

[8] Australasian Menopause Society. Position Statement on Menopausal Hormone Therapy. menopause.org.au