Lisa L. Savage, M.D. received her M.D. from Baylor College of Medicine in Houston, Texas and did her residency training at Emory in Atlanta, Georgia. She and her husband returned to her home state of Texas following residency, and Dr. Lisa practiced in Austin for 25 years before closing her solo office in 2017 to take a sabbatical. She did obstetrics for the first 10 years in practice, then focused on gynecology thereafter, seeing women of all ages for preventive and problem-focused care.
If a woman decides to use hormone replacement therapy (HRT), there are several options for how to do so, each with different HRT pros and cons, and largely subject to personal preference when choosing. Delivery systems include both systemic (total body) and local (vulva/vaginal) therapy.
Systemic therapy is used to treat symptoms such as hot flashes and night sweats in perimenopause or menopause, whereas local therapy is used either alone or in combination with systemic therapy to treat just the vulva and vagina, with very little to no significant systemic effect.
The original systemic products were in pill format, something familiar and easy to take. Some of the most commonly used products are daily pills. Patients find that delivery system easy to integrate into their routine when they are already taking other medications in pill form.
There are pills which contain just estrogen (or a combination of estrogens), just progestin (necessary to protect the uterine lining from estrogen-induced overgrowth), and pills which contain both hormones together.
The combination products are convenient, though they have a limited number of dosage and ratio options. Taking each hormone separately can allow for individual adjustment of the two components when necessary to achieve the right balance for a particular situation. So, while one patient might do well with a combination pill, another might take them separately, needing to take two daily pills instead of one. For women who have had a hysterectomy, only the estrogen component is needed, eliminating the need for a combination or second pill.
The best way to know where you are in the menopause journey is by understanding cycles and symptoms. Gennev's Menopause Assessment is a great tool for understanding your body better.
Transdermal or across the skin methods are also available for systemic dosing. Skin patches, either with estrogen alone or with both estrogen and progestin, are usually applied/changed either once or twice a week.
Patches are applied to the abdomen, thigh or buttocks and generally stay on quite well. They are meant to stick through what I call the three Ss: shower, sweat, swim. They can leave a sticky residue, needing some scrubbing or lotion/body oil to remove the adhesive. Some patients with oily or sensitive skin find that patches don't stick well or cause a skin reaction, but many women find them to be an attractive delivery system.
The main advantage to all transdermal delivery systems is that they bypass the digestive tract, specifically the liver, which means they convey less risk of blood clotting complications. Transdermal systems can thus be the best choice when minimizing this risk is important.
There is also a vaginal ring for the systemic delivery of estrogen, which has the advantage of being changed by the patient just once every three months, and a vaginal gel for the systemic delivery of progestin.
Other transdermal products for the delivery of estrogen are sprays and gels applied to the arm, which require a bit more effort (daily dosing, need to wait for it to dry) than patches, but without the adhesive to deal with.PelletsLess commonly used are implantable pellets inserted under the skin in an office procedure.
Here at Gennev this is not a delivery system that we recommend, as these pellets are not an FDA-approved form of medication and can be irregular and high in dosing. Additionally they have no published evidence of safety or improved outcomes and are not covered by insurance.
Progestin-containing (IUDs intrauterine devices) are in another category, originally designed for premenopause and pregnancy as a contraception. They can be used to provide uterine lining protection when a systemic estrogen, via one of the delivery systems described above, is being used.This example illustrates that it is possible to safely mix and match delivery systems when individualizing therapy and minimizing side effects. The art of medicine can come into play when designing a regimen for a particular patients needs.
Delivery systems for vulva/vaginal estrogen therapy include several options. With vaginal therapy, blood levels of estrogen do not change compared to not using them, so they may be considered safe to use for local symptoms even if systemic therapy is not desired or possible.
Local therapy alone is a great option when the main symptoms are vaginal issues such as dryness/atrophy and not systemic, such as hot flashes. In that case it may be the preferred approach, as it allows avoidance of systemic side effects and potential risk.
The original products for vaginal therapy were estrogen creams, applied inside the vagina with a reusable applicator (it looks like a tampon applicator) as well as on the vulva. Creams have the advantage of allowing for a dedicated amount of product to be applied to the vulva, and some patients use it only externally. While very little cream is needed per dose, it may be considered messy by some users.
The next generation of vaginal products therefore was developed to deliver estrogen in a dry tablet inserted with a disposable applicator. The vaginal tablet system has the advantage of being very neat, albeit without the ability to apply it externally (to the vulva, for instance).
There is also a vaginal ring designed just for vaginal (not systemic) estrogen delivery, changed by the patient every three months. Speaking of the rings, whether for systemic or vaginal dosing, they are generally easy for the patient to manage, although I had a handful of patients who had me remove/replace their rings, some because of hand arthritis or other dexterity limitations, and others because they just had a preference for in-office ring change. One of the newest products is a vaginal insert that delivers DHEA for menopause (a precursor to some sex hormones, including estrogen) vaginally.
There is one more delivery system for vaginal therapy, though it is not a hormone per se. It is an oral tablet that affects estrogen receptors in certain tissues (vagina, uterus) but not others. So, it is taken by mouth but intended to have only local effects.
Clearly there are a lot of options for both the systemic and local delivery of hormonal therapy. It can seem like a daunting array of choices, and sometimes trial and error is part of figuring out which delivery system or combination of systems works best for a patient.It may take several weeks to know how a delivery system/dosage/ratio is going to work out. Scheduling a follow-up appointment at an interval of 2-3 months is a reasonable timeframe; any sooner may not be long enough to allow for adjustment.
I recommend you print this out and take it with you to your next doc or ob/gyn appointment so your doc can take you through all the options. Working with an experienced medical professional can help you navigate the choices and find what works best for your symptoms, medical history and lifestyle. If you're ready to talk with a menopause specialist, book an appointment today, and get the answers you need from the comfort of your own home.
Dr. Lisa is married to an Orthopedic Surgeon, and they have a young adult daughter and a rescue dog. Her hobbies include reading, travel, and a new-found interest in physical fitness, specifically rowing. She volunteers with a canine rescue group and a homeless ministry.What HRT delivery method have you tried or are you considering? Why does one option sound more or less attractive than the others? Let us know your thoughts in the community forums, share with us on Gennev's Facebook page, or join Midlife Menopause Solutions, our closed Facebook group.
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