If estrogen is only required for vaginal or urinary symptoms, vaginal estrogen is available in the form of a tablet, cream, pessary or vaginal ring. If estrogen is required for more general symptoms such as flushes, sweats, joint aches or poor sleep, then it is taken in a form which circulates throughout the body and is known as systemic HRT. Systemic estrogen can be taken as a daily tablet, a weekly or twice weekly patch, daily gel, or a 6 monthly implant. Estrogen combined with progestogen can be taken by tablet or weekly or twice weekly patch, and progestogen alone can be taken by tablet, vaginal gel or by the progestogen releasing intra-uterine system-Mirena. The different routes of estrogen used have different metabolic effects (e.g. on clotting factors and blood fats) but the implications of the differences is controversial and the main factors determining choice of route are individual preference, response and past medical history. Most often, HRT is started in tablet form.

Indications for non-tablet route.

• Individual preference.
• Poor symptom control with tablet HRT.
• Side effects such as nausea with tablet.
• Bowel disorder which may affect absorption of tablet therapy.
• History of migraine (when steadier hormone levels which may be achieved with a patch may be beneficial).
• Lactose sensitivity (all tablet preparations of HRT contain lactose).
• History of gallstones.
• Current use of medications such as anti-epileptic medication which may interfere with the break-down of tablet HRT.
• Variable blood pressure.
• High triglyceride levels.