Types of HRT and Their Pros & Cons
Hormone Replacement Therapy (HRT) has become a hot topic—and for good reason. As more women prioritize their long-term health, energy, and vitality, they’re looking for real, lasting solutions to the hormonal drops that can happen anytime in life and become especially pronounced in perimenopause and menopause.
You’ve probably heard that HRT can help with hot flashes, brain fog, sleep disruption, anxiety, depression, irritability, thinning hair, vaginal dryness, and more. And yes, it can be truly life-changing. But what most women don’t realize is this:
Not all hormone replacement therapy is created equal for women. There isn’t just one type, or formulation, rather there are many with differences in how they make women feel.
Should you choose a patch or a pill? What about creams or sprays? What about injections or pellets? Are bioidentical hormones the same as synthetic? What about just replacing progesterone and testosterone but not estradiol? Does every woman need progesterone? What actually works—and what just adds confusion?
I’m Dr. Sarah Daccarett, MD, and I’ve guided thousands of women through hormone restoration at Inner Balance, combining personalized care with the latest science in functional and longevity medicine. My goal today is to help you understand the different types of HRT available—so you can make a confident, informed decision about what’s best for you.
Let’s dive in.
What Types of Hormone Replacement Therapy Are There?
HRT is not one-size-fits-all—and it shouldn’t be. Your age, body, metabolism, genetics, history, and goals are unique. That’s why your HRT plan should be, too.
Below, I’ll walk you through the most common types of HRT, what they’re used for, how they work, and what their pros and cons are.
- Tablets (Oral HRT)
- Skin Patches
- Estrogen Gel, cream, or spray
- Intrauterine System (IUS)
- Vaginal Estradiol
- Hormone Pellets
- Troches
- Topical Progesterone
- OestraTM (Inner Balance Signature Protocol)
Tablets (Oral HRT)
What is it?
Primarily used to restore estradiol, testosterone and/or progesterone levels. Typically taken once or twice daily. Often contains synthetic or bioidentical hormones. Some formulations also include synthetic progestins, and conjugated estrogens. Its a simple pill that you can take daily.
Pros
- Convenient and familiar
- Often covered by insurance
Cons
- Slight, very low Increase in the risk of blood clots due to first-pass liver metabolism
- Not ideal for women with cardiovascular risk or migraines
- May impact liver enzymes and hormone-binding proteins
- Can increase blood pressure
- 80% of Oral progesterone converts to metabolites that have many side effects such as weight gain, daytime sleepiness, acne, bloating and irritability. Can make PMDD worse.
My Take: While oral HRT can be effective for some, most still have symptoms on it and side effects are common. I rarely recommend it as a first-line treatment—especially when better, safer options exist.
Skin Patches
What is it?
Typically delivers estradiol (and sometimes progesterone) transdermally, bypassing the liver. Usually bioidentical estradiol alone in micromilligrams (microdoses). Applied 1–2 times weekly to the abdomen, buttocks, or lower back.
Pros
- Steady hormone delivery
- Lower clotting risk than oral HRT
- Bypasses liver
Cons
- Can cause skin irritation, rashes, or allergies.
- Difficult to bathe, sauna, or swim
- May peel off with sweat or friction
- Adhesive can be bothersome
- Still have to pair with oral progesterone
My Take: Patches in combination with micronized oral progesterone are a great option for postmenopausal women who don’t want to have any uterine bleeding. However, it is ineffective for a lot of women, especially perimenopausal women and most still experience symptoms with an estradiol patch and progesterone pill. Estradiol will not typically get above 60 pg/mL on lab testing, which often isn’t high enough to stop hot flashes, or many other symptoms.
Estrogen Gel, cream, or spray
What is it?
Systemic estradiol, estriol, or combination of the two. Typically bioidentical. Applied daily to clean, dry skin—commonly on upper arms or thighs.
Pros
- Easy to fine-tune the dose
- Bypasses liver
- Lower risk of clotting
Cons
- Must dry fully before dressing
- High transfer risk if skin contacts others, or laundry is done with others in the hoe
- Variable absorption depending on skin type and application site
- Only 30% typically is able to absorb
My Take: I rarely use topical creams due to the ineffective and variable absorption, and high risk of transfer to kids, pets and partners. love gels for their flexibility, especially when titrating doses. But they require a bit more mindfulness in terms of routine and avoiding contact transfer.
Intrauterine System (IUS) – e.g., Mirena Coil
What is it?
Contraception, but often still used as hormone replacement therapy in women who don’t need a birth control option. It is typically made of Levonorgestrel—a synthetic progestin (not progesterone). It is inserted by a provider, remains in place for up to 5 years. It may reduce bleeding by suppressing the production of estradiol and progesterone.
Pros
- Long-acting
- Convenient, no daily dosing
Cons
- Not bioidentical
- May cause mood changes, weight gain, irritability, hair loss or spotting
- Insertion can be painful and removal can cause symptoms for many days
My Take: Not my go-to for hormone replacement therapy due to its synthetic nature and non-holistic approach. Progestin doesn’t act the way natural progesterone does in the body. Women can still keep it if pregnancy is a concern and they are ready to start hormone replacement therapy.
Vaginal Estradiol (Low Dose, Non-systemic)
What is it?
Helps to restore vaginal tissue health—targets dryness, itching, pain, and UTIs. Bioidentical estradiol or estriol in cream, ring, or tablet form. Typically applied 2–3 times per week, depending on severity and type. It helps to revive tissue elasticity, moisture, and pH balance.
Pros
- Can be an option for women who don’t want HRT, but need relief from vaginal dryness.
Cons
- It only helps with vaginal dryness and no other symptoms.
- Many pharmaceutical creams cause burning and itching on application
- Not a whole-body holistic approach to hormone replacement therapy and must be paired with 2-3 other forms.
My Take: Not effective at treating the whole-body. Only treats one symptom – vaginal dryness. Not an effective systemic solution for any woman. A good option for some women who don’t want HRT, but just want something to help with vaginal dryness.
Hormone Pellets
What is it?
Delivers a steady dose of hormones—usually estradiol and/or testosterone—implanted under the skin for about 3 months. Typically compounded bioidentical hormones pressed into solid pellets. They are inserted via a small incision in the hip or buttock area by a healthcare provider every few months.
Pros
- Long-lasting (no daily routine)
- No risk of forgetting doses
- Good for women who dislike applying products
Cons
- Not adjustable once inserted—can’t lower dose if side effects arise.
- Peaks early, then declines—some women feel the “crash” before the next insertion
- May cause testosterone excess or side effects like weight gain acne, irritability, or hair thinning
- Requires in-office procedure
- Usually not covered by insurance and is expensive
- No biodentical progesterone pellet, so you still have to take oral progesterone (even more side effects)
My Take: Once they’re in, you can’t “undo” the dose—so if you’re sensitive to hormones, it’s a big risk. They also don’t allow for easy titration, which is key to optimal hormone balance. Plus, testosterone pellets and oral progesterone combination gives a lot of side effects like weight gain, and hair thinning. I don’t typically recommend them as a first-line option, especially when other flexible, safer, and more personalized methods exist.
Troches (Sublingual Lozenges)
What is it?
Delivers hormones—most often progesterone, estrogen, or testosterone—through the mucous membranes in the mouth. Usually compounded, bioidentical hormones in a flavored dissolvable tablet. Placed under the tongue or between the cheek and gum once or twice daily. Ideally you get systemic absorption by bypassing the liver.
Pros
- Custom-compounded with specific doses
- Easy to use and relatively fast-acting
- Better absorption than oral pills in some cases
- Avoids gastrointestinal side effects sometimes
Cons
- Can be inconsistent in absorption based on saliva and placement
- Some find the taste unpleasant or chalky
- Needs to dissolve fully—can be time-consuming
- Often not covered by insurance and is very expensive
- Not ideal for all hormones (especially progesterone—more on that below) because progesterone doesn’t absorb and is swallowed and can cause daytime sleepiness because once swallowed – it is metabolized by the liver.
My Take: They’re often overused as a “catch-all,” which can backfire if absorption is inconsistent. Not my first choice since it takes a lot of patience to wait for them to absorb and most end up swallowing a significant amount of hormone – which results in liver metabolism and side effects. In addition, they are more expensive than other options.
Topical Progesterone (Creams & Gels)
What is it?
Delivers bioidentical progesterone through the skin. Compounded or over-the-counter micronized progesterone. Applied daily to thin-skinned areas like the inner arms, thighs, or abdomen.
Pros
- Easy to use, gentle application
- Avoids liver metabolism
- Custom-compounded if needed
Cons
- Unreliable absorption; serum levels don’t always reflect tissue effect.
- May not adequately protect the endometrium (uterine lining) if used with systemic estradiol. Progesterone doesn’t absorb through the skin.
- Often misused or under-dosed when self-prescribed
- Not recommended for endometrial protection
My Take: This is a big one. Many women—and even some practitioners—rely on topical progesterone for symptom relief. But in terms of clinical efficacy, I don’t trust it for uterine protection or consistent results. It simply doesn’t absorb reliably enough. For women with a uterus on systemic estradiol, Topical progesterone may offer some benefits for mood or sleep, but it’s not strong enough for a holistic whole body approach to hormone replacement therapy for women.
OestraTM (Inner Balance Signature Protocol)
What is it?
Oestra is a comprehensive, whole body, personalized hormone replacement therapy protocol created by Inner Balance. It is designed to restore whole body levels using bioidentical estradiol and progesterone. And since your body converts progesterone into testosterone, it also balances testosterone in women too. Oestra targets full-body symptoms as well as local vaginal health for optimal longevity, vitality, and sex drive.
Composition
- Plant based, bioidentical estradiol (systemic)
- Micronized progesterone (systemic) All hormones used in Oestra are bioidentical, meaning they structurally match the hormones naturally produced by your body.
Pros
- Systemic and all-in-one. No need to combine multiple products.
- Uses only bioidentical hormones
- Addresses full spectrum of symptoms and health risks
- Individually customized and titrated over time
- Delivered via telehealth and shipped to your door
- Ongoing care and lab monitoring included
Cons
- Typically not covered by insurance (especially compounded medications)
- Takes a few weeks to fully notice benefits
- Vaginal application may be new or unfamiliar for some women
My Take: I created Oestra because the conventional HRT model wasn’t cutting it. Too many women were being handed one product and told “good luck.” That’s not how female physiology works—and that’s not how we get results. Oestra is my clinical gold standard: a comprehensive, bioidentical, precision-based approach to hormone therapy that supports women from the inside out. It’s not about chasing lab intervals and side effects. It’s about building real, sustainable hormone health that supports longevity, energy, and joy for the long haul. For many of my patients, it’s the first time they’ve felt seen, heard, and truly balanced.
Most women don’t realize that you can’t treat everything with just one type of HRT.
Which HRT Type Is Best?
Here’s the truth: there’s no universal “best” option.
The right therapy depends on your age, metabolism, symptoms, medical history, lifestyle, goals, and preferences.
At Inner Balance, we customize your plan – if you need extra supplement support we are here for you.
We also consider long-term benefits like bone density, cardiovascular protection, brain function, and metabolic health—not just symptom relief.
That’s why I created Oestra—our flagship HRT program that combines bioidentical therapy, telehealth care and expert support in one powerful protocol.
Additional Considerations
Costs and Insurance
- Covered by insurance: Oral pills, some patches
- Not covered: Compounded creams, lozenges, pellets (cash-pay)
- Pellets: Convenient for some, but I don’t recommend them as first-line due to unpredictable dosing and difficulty adjusting
Telehealth Care
With secure telemedicine, women everywhere can now access elite, personalized hormone care. At Inner Balance, we offer:
- Custom prescriptions (including compounding options)
- Ongoing care, adjustments, and check-ins—all online
Final Thoughts: It’s About Your Balance
HRT isn’t just about easing bad aging symptoms. It’s about preserving your energy, confidence, and healthspan for decades to come.
Here’s the thing: hormones aren’t something to fear. They’re something to work with. Wisely, confidently, and intentionally. Whether you’re just starting to explore HRT or already on a journey that needs refining, I want you to know this:
You deserve personalized care. You deserve science-backed answers. And you deserve to feel amazing in your body again.
Let’s find your balance, together.
