What Kind of HRT for Menopause? Types Matched to Your Symptoms and Situation
| Your main situation | Category usually discussed first |
|---|---|
| Hot flashes or night sweats | Whole-body (systemic) estrogen |
| Vaginal dryness or painful sex only | Low-dose vaginal (local) estrogen |
| Whole-body estrogen and you have a uterus | You’ll also need to protect the uterine lining |
| Several factors pulling in different directions | Map it before you choose a provider |
Here’s the honest part, up front: there is no single “best kind” of HRT for every woman. Anyone who hands you one answer without knowing your symptoms, your uterus status, and your history is skipping the very facts that decide it. We’ll walk you through each fork in plain language, show you which category fits situations like yours, and get you into your first appointment knowing what to ask — instead of nodding along to terms you’ve never heard.
This guide is for you if…
- HRT might help, but the options are a blur of overlapping names
- You want to walk into a consult prepared, not sold to
- You want the plain difference between systemic and local, estrogen-only and combined, patch and pill, bioidentical and compounded
This guide is not enough if…
- You’re trying to pick your own dose — that’s a clinician’s job
- You have unexplained vaginal bleeding, or a history of blood clots, stroke, liver disease, or a hormone-sensitive cancer
The HRT Index is the independent decision resource for online menopause and HRT care — comparing telehealth providers on clinical legitimacy, care quality, medication fit, price transparency, and access, with every claim verified and dated.
What kind of HRT for menopause is usually considered first?
There’s no one product everyone uses. Choosing a “kind” of HRT really means working through five connected decisions: where your symptoms are, whether you still have a uterus, whether you still get periods, which route you’d use, and whether an FDA-approved product fits or a clinician finds a reason to compound one.
The five forks, in order:
- Symptom location. Are your symptoms all over your body (hot flashes, night sweats, sleep disruption), or mostly in one place (vaginal dryness, painful sex, urinary changes)?
- Uterus status. Do you still have your uterus? This decides whether you need to protect the uterine lining.
- Period and contraception status. Still getting periods? Then treating menopause symptoms and preventing pregnancy are two separate questions.
- Route.Pill, patch, gel, spray, or vaginal — sometimes the same hormone delivered differently, but the product, dose, and route all matter.
- FDA-approved or compounded.A regulatory difference that affects testing, dosing consistency, and what’s actually known about safety.
The HRT Type Decision Matrix
A pre-consult map — not a prescription. Educational only. Sources for each row: The Menopause Society 2022 Hormone Therapy Position Statement; ACOG 2023 Clinical Consensus; Duavee FDA prescribing information; Global Consensus Position Statement on Testosterone Therapy for Women (2019). Checked June 2026.
| If this is you | Category usually discussed first | Key question to ask | Flag |
|---|---|---|---|
| Hot flashes / night sweats, uterus intact, no clot or hormone-cancer history | Systemic estrogen plus lining protection (a progestogen, or the conjugated estrogens/bazedoxifene combination); route chosen individually | “Which protection strategy, and which route, fits me?” | — |
| Hot flashes / night sweats, no uterus (hysterectomy) | Systemic estrogen alone | “Patch, gel, or pill for my situation?” | — |
| Mainly vaginal dryness, painful sex, or recurrent UTIs | Low-dose vaginal (local) estrogen | “Is local enough, or do I also need whole-body treatment?” | — |
| Both whole-body and vaginal symptoms | Discuss systemic therapy for body-wide symptoms, and whether local GSM treatment is needed now or after a reassessment | “Do we treat both at once or reassess the vaginal symptoms later?” | — |
| Still having periods / may need contraception | Treat symptoms and contraception as separate decisions | “How do we handle both — and is this birth control?” | — |
| Migraine, including with aura | If systemic HRT is otherwise appropriate, transdermal estradiol is commonly preferred for steadier hormone levels | “Does my migraine pattern change the route or dose?” | ⚠️ Clinician-led |
| Prior blood clot or stroke | Don’t use this table to pick a route — systemic hormones are generally not advised or need specialist assessment | “Is systemic HRT appropriate for me at all?” | ⚠️ Specialist assessment |
| History of breast or other hormone-sensitive cancer | Whole-body hormones often not appropriate; ask about non-hormonal options | “What are my non-hormonal choices?” | ⚠️ See a specialist first |
| Want a "bioidentical" option | Ask about FDA-approved estradiol — and FDA-approved progesterone (or another protection strategy) only if you need lining protection | “Is what you’re recommending FDA-approved or compounded?” | — |
| Early menopause, primary ovarian insufficiency, or surgical menopause (both ovaries removed) | A more specialized replacement plan, not a generic menopause routine | “How are my goals and dose different because of this?” | ⚠️ Specialized care |
| Unexplained bleeding or another unresolved red flag | In-person evaluation before any online treatment choice | “What needs to be ruled out first?” | ⚠️ Evaluate in person |
Rules this table teaches that thinner pages skip: whole-body estrogen treats body-wide symptoms; low-dose vaginal estrogen treats local symptoms; a uterus generally means lining protection with systemic estrogen; a prior clot or stroke is a different category from a migraine and can’t share one route answer; and “vaginal” does notautomatically mean “local.”
Do I need whole-body (systemic) HRT or low-dose vaginal estrogen?
Systemic therapy treats symptoms across your whole body — it’s the category used for hot flashes and night sweats. Low-dose vaginal therapy primarily treats vaginal symptoms and some urinary symptoms linked to menopause, with very little hormone reaching the rest of the body. Many women fit clearly into one; some need a conversation about both. (Source: The Menopause Society, hormone therapy patient education.)
Systemic (whole-body) HRTmeans the hormone reaches your bloodstream at a level meant to affect your whole body. It’s the category for vasomotor symptoms— the medical name for hot flashes and night sweats. It comes as a pill, patch, gel, spray, or certain rings.
Low-dose vaginal estrogenacts mainly in the vaginal and nearby urinary tissue. It’s the category for GSM— genitourinary syndrome of menopause, the umbrella term for vaginal dryness, burning, painful sex, and some urinary symptoms. It comes as a cream, tablet, insert, or low-dose ring. Because so little hormone enters the bloodstream, it’s generally a low-risk option.
What if you have both?Whole-body estrogen often improves more than one symptom group, so it may help vaginal symptoms too. If dryness sticks around after your hot flashes settle, that’s worth raising again — sometimes a local treatment is added. Don’t assume one prescription has to fix everything, and don’t add anything on your own.
For a deep dive into low-dose vaginal therapy specifically: Vaginal estrogen: products, safety, and what to expect →
Do I need progesterone if I take estrogen?
If you have a uterus and use systemic estrogen, your plan generally needs to protect the uterine lining — usually with a progestogen, or in one FDA-approved regimen, with bazedoxifene combined with conjugated estrogens. Estrogen alone can overstimulate that lining and raise the risk of endometrial (uterine) cancer. If you’ve had a hysterectomy, estrogen alone is often used, but the reason for surgery and your full history still matter. (Source: The Menopause Society 2022; Duavee FDA prescribing information.)
A quick vocabulary fix, because the words trip everyone up:
- Estrogen is the main hormone that drops at menopause and drives most symptoms.
- Progesterone is the natural partner hormone. Progestogen is the umbrella word for progesterone and its lab-made cousins. Progestin usually means a synthetic version. Micronized progesterone (brand name Prometrium) is the FDA-approved bioidentical form.
- Combined HRT means estrogen plus lining protection. It does notalways mean two hormones in one pill — they can be separate products.
| Your situation | Typical lining-protection approach |
|---|---|
| Uterus + systemic estrogen | A progestogen (such as micronized progesterone), or the FDA-approved conjugated estrogens/bazedoxifene combination — which protects the lining without a progestin |
| No uterus (hysterectomy) | Usually estrogen alone — confirm your surgical history with your clinician |
| Low-dose vaginal estrogen | Routine progestogen is generally not recommended; report any bleeding, and note that long-term lining-safety data beyond one year are limited |
| Hormonal IUD as the progestogen | A 52-mg levonorgestrel IUD is sometimes used off-label in the US as the progestogen part of an estrogen plan and may also provide contraception; your clinician confirms the device, duration, and fit |
One rule on bleeding, used the same way everywhere: any postmenopausal bleeding should be reported to the prescribing clinician. Whether it needs a diagnostic work-up depends on its timing, pattern, your regimen, and your risk factors — it should never be brushed off as “just adjusting.”
Full guide: Do you need progesterone if you have a uterus? →
Is a patch, pill, gel, or vaginal the better HRT route?
No route is safest for everyone. Oral systemic estrogen is associated with higher blood-clot (VTE) risk than transdermal estrogen; transdermal risk is lower, not zero, and much of the comparison comes from observational evidence. Route is one major part of the safety discussion — hormone type, dose, timing, and medical history matter too. (Source: The Menopause Society 2022; observational studies including Circulation 2007; NICE 2024 guidance.)
When you swallow estrogen, it passes through your liver first (the “first-pass effect”), which nudges up certain clotting proteins. A patch or gel delivers estrogen through the skin — this is what transdermalmeans — skipping that first liver pass. Observational evidence generally links oral estrogen with higher VTE risk (venous thromboembolism, a blood clot in a vein) than transdermal estrogen; transdermal is lower risk, not no risk.
| Route | FDA-approved examples | Usually systemic or local? | Route-risk note | Question to ask |
|---|---|---|---|---|
| Pill | estradiol (Estrace), conjugated estrogens (Premarin) | Systemic | Higher VTE risk than transdermal (first-pass liver) | “Does my history give me a reason to avoid oral estrogen?” |
| Patch | estradiol patch (Vivelle-Dot, Climara, Minivelle, Dotti) | Systemic | Lower VTE risk than oral; not zero | “How often is this specific patch changed?” |
| Gel / spray | EstroGel, Divigel, Evamist | Systemic | Lower VTE risk than oral; not zero | “Where do I apply it, and how long before skin contact with others?” |
| Vaginal cream / tablet / insert | Estrace cream, Vagifem/Yuvafem, Imvexxy | Usually local at low dose | Minimal systemic absorption relative to systemic estrogen; product labeling still applies | “Is this a local-dose or a systemic-dose product?” |
| Vaginal ring | Estring (local) or Femring (systemic) | Can be either | Depends on the product | “Is this particular ring local or systemic?” |
| Intravaginal prasterone | Intrarosa | Local | Prasterone (DHEA), not an estrogen; prescription treatment for painful sex due to menopause | “Is prasterone or low-dose vaginal estrogen the better local option for me?” |
| Hormonal IUD | levonorgestrel IUD | Delivers a progestogen in the uterus; not an estrogen | Used off-label in the US as the progestogen part of an estrogen plan | “Can this provide the lining protection my estrogen plan needs?” |
Should HRT be cyclic or continuous?
Cyclic (or “sequential”) HRT uses estrogen every day and adds a progestogen for part of each month, which usually causes a scheduled withdrawal bleed. Continuous-combined HRT uses both hormones every day, aiming for no scheduled bleed. Where you are in the transition, your bleeding pattern, and your preferences guide the choice. (Source: NHS, types of HRT.)
Cyclic / sequential HRT is commonly discussed in perimenopause(the lead-up to menopause, when you’re still getting periods but they’re changing). You take estrogen daily and add the progestogen for part of the month, which usually produces a planned, period-like bleed.
Continuous-combined HRT is commonly discussed after menopause(defined as 12 months with no period). Both hormones are taken every day, aiming for no scheduled bleed. Some irregular spotting can happen early — and any postmenopausal bleeding should be reported to your clinician.
Still having periods? See our full perimenopause guide →
Are “bioidentical” and compounded HRT the same thing?
No. “Bioidentical” is a nonregulatory term for a hormone that is chemically identical to one your body makes — and several FDA-approved products already are, including estradiol and micronized progesterone. “Compounded” means a preparation made by a compounding pharmacy rather than approved by the FDA as a finished drug. So “bioidentical” describes chemistry; it does not establish FDA approval, quality, safety, or superiority. (Source: FDA, Menopause consumer page; The Menopause Society; ACOG 2023 Clinical Consensus.)
| FDA-approved HRT (includes bioidentical estradiol & micronized progesterone) | Compounded “bioidentical” (cBHT) | |
|---|---|---|
| Regulatory review | FDA-reviewed evidence supporting approval, or demonstrated bioequivalence to a reference product | FDA does not review the finished compounded product for safety, effectiveness, quality, or dosing before marketing |
| What guidelines say | Use an FDA-approved product when one meets the clinical need | ACOG & The Menopause Society: not routine; reserve for a documented need, such as an allergy to an FDA-approved product |
| Insurance | Coverage varies by the exact product and plan; verify with the insurer and dispensing pharmacy | Coverage varies by the exact product and plan; verify with the insurer and dispensing pharmacy |
| “Bioidentical” label | Some FDA-approved products are bioidentical | A marketing term, not a safety guarantee |
Specific detail worth knowing: the FDA has not approved any drug containing estriol(a weaker form of estrogen that shows up in some compounded “bi-est” formulas). The FDA has stated it does not have evidence that estriol is safe and effective or a “safer form of estrogen.” Any US estriol preparation offered for menopause is a compounded product, not an FDA-approved finished drug. If a provider offers you estriol, ask them to say so directly.
Four questions to ask before you pay anyone:
- Is what you’re prescribing FDA-approved or compounded?
- What’s the exact drug and route?
- Which pharmacy fills it?
- What documented reason supports compounding instead of an FDA-approved option?
Where the categories live (factual examples, not a ranking; provider-stated, checked June 2026):Some insurance-based telehealth services — Midi Health, for instance — prescribe FDA-approved estradiol and progesterone (available in all 50 states and in-network with most PPO plans; cannot treat Medicaid patients; Medicare beneficiaries may use as self-pay). Some bioidentical-focused services — Winona, for instance — state that their estradiol patches, tablets, and progesterone capsules are FDA-approved, while their body creams are compounded and are not FDA-approved finished products (Source: bywinona.com; confirm at prescribing).
What did the FDA change on HRT labels in 2026?
On February 12, 2026, the FDA approved updated labels for six named menopausal hormone products — Prometrium, Divigel, Cenestin, Enjuvia, Estring, and Bijuva — removing boxed-warning statements about cardiovascular disease, breast cancer, and probable dementia from those labels. This was not a blanket removal of all warnings from every HRT product; systemic estrogen-alone products keep boxed-warning language about endometrial cancer. (Source: FDA, “FDA Approves Labeling Changes to Menopausal Hormone Therapy Products,” Feb 12, 2026.)
For 20-plus years, many women avoided HRT because of warnings tied to a 2002 study called the Women’s Health Initiative. The FDA has now revisited that — but the action so far is specific, not sweeping. The first six products to get updated labels:
| Product | Category |
|---|---|
| Prometrium | Progestogen alone |
| Divigel | Systemic estrogen alone |
| Cenestin | Systemic estrogen alone |
| Enjuvia | Systemic estrogen alone |
| Estring | Topical vaginal estrogen |
| Bijuva | Systemic estrogen + progestogen |
- It’s product-specific.Don’t assume a specific medicine’s label has already changed — check the current label.
- The systemic estrogen-alone endometrial-cancer warning remains.That’s why women with a uterus need lining protection.
- The new labels emphasize timing. The benefit-risk balance is generally most favorable when systemic HRT is started before age 60 or within 10 years of menopause.
- There’s balance to hold here. The Menopause Society broadly supported easing the warning on low-dose vaginal estrogen, while noting that whole-body estrogen still carries real risks for some women.
Full guide: what actually changed in the 2026 FDA HRT warning →
What changes the answer if I have migraines, clot risk, a cancer history, or I’m over 60?
These don’t all lead to the same place. Some shift you toward a particular route; others may make whole-body hormones inappropriate or call for specialist care. Unexplained bleeding, a past blood clot or stroke, liver disease, and certain cancer histories should not be sorted out by a generic online recommendation.
Migraine may influence route selection. If systemic HRT is otherwise appropriate, transdermal estradiol is commonly preferred, because it produces steadier hormone levels. A prior blood clot or stroke is a different category entirely. That requires a direct assessment of whether systemic HRT is appropriate for you at all— not just a switch from pill to patch. A lower-risk route does not cancel out a contraindication.
Starting after 60, or more than 10 years after menopause. This isn’t an automatic “no” — it’s a “be more careful.” The benefit-risk math shifts as you get further from menopause, and it deserves an individualized look at your symptoms, your absolute risks, and your alternatives.
Early menopause, POI, or surgical menopause. POI (primary ovarian insufficiency) is loss or dysfunction of normal ovarian activity before age 40. Menopause before the typical age usually calls for a different plan, often with different goals and duration than treating ordinary, age-expected menopause.
For the full breakdown of how benefits and risks shift by route, timing, and history: How HRT benefits and risks change by route and history →
Do I need hormone tests to choose a kind of HRT?
Usually, a single hormone blood level doesn’t pick your HRT on its own. Your symptoms, menstrual history, uterus status, age, medical history, and goals carry the decision. Testing can still matter when the diagnosis is unclear, when menopause comes unusually early, when pregnancy is possible, or when another condition needs checking.
Hormone levels fluctuate substantially across perimenopause, so one measurement may not represent the overall pattern. Diagnosis and treatment lean more on your story than on a number. Testing isn’t useless — a clinician may order it to sort out an uncertain diagnosis, check your thyroid, evaluate possible early menopause, or rule out pregnancy. The point isn’t “never test.” It’s “don’t expect a lab to choose your dose.”
One thing to steer away from: salivary hormone testing marketed to “customize” your dose. ACOG states that salivary testing does not provide an accurate or precise assessment for tailoring menopausal hormone therapy, and it’s often paired with compounded products. (Source: ACOG 2023 Clinical Consensus.)
What about testosterone for menopause?
For women, the only evidence-based reason to use testosterone is treating distressing low sexual desire (called HSDD) in postmenopausal women, after a careful assessment. No testosterone product is FDA-approved for women in the US, so it’s prescribed off-label. It may be used with or without estrogen, and it remains a Schedule III controlled substance that requires a prescription and monitoring. (Source: Global Consensus Position Statement on Testosterone Therapy for Women, 2019; ACOG 2023.)
- No FDA-approved female testosterone product exists. When it’s used, clinicians aim to keep levels in the normal female range and monitor blood levels.
- Compounded testosterone and pellets are not recommended by the international consensus. Pellets in particular aren’t recommended because the dose can’t be readily adjusted after implantation.
- Testosterone is a Schedule III controlled substance in the US. It requires a prescription and proper medical oversight — there’s no legitimate shortcut.
What if I can’t or don’t want to take hormones?
You still have real options. FDA-approved non-hormonal prescription options for moderate-to-severe hot flashes include Brisdelle (a low-dose paroxetine), Veozah (fezolinetant), and Lynkuet (elinzanetant), which the FDA approved on October 24, 2025. These don’t replace estrogen, but for many women they help. (Source: FDA approvals — Brisdelle 2013, Veozah 2023, Lynkuet 2025.)
| Option | Type | FDA-approved | Key safety note |
|---|---|---|---|
| Brisdelle (paroxetine 7.5 mg) | Non-hormonal (an SSRI) | 2013, for hot flashes | Standard SSRI precautions; discuss with your clinician |
| Veozah (fezolinetant) | Non-hormonal (NK3 receptor) | 2023 | Boxed warning for rare but serious liver injury; requires liver blood tests before starting, monthly for the first 3 months, and again at months 6 and 9 |
| Lynkuet (elinzanetant) | Non-hormonal (NK1/NK3 receptor) | Oct 24, 2025 | Newer option; review current labeling with your clinician |
Brisdelle is an FDA-approved paroxetine formulation for hot flashes; other SSRIs, SNRIs, and gabapentin are commonly used off-label for vasomotor symptoms. See our full non-hormonal options guide →
How will I know if the kind of HRT needs changing?
The real test isn’t whether a regimen sounds ideal on paper. It’s whether the symptoms that sent you to treatment actually improve, without side effects you can’t live with or bleeding that worries you. Starting HRT is rarely “set it and forget it.”
Track what sent you in. A simple weekly note gives your clinician something concrete: hot flashes and night sweats (how often), sleep interruptions, vaginal discomfort or pain with sex, mood and daily function, any side effects, and any bleeding.
Treat “route friction” as a valid reason to revisit.A patch that won’t stay on, a gel that doesn’t fit your mornings, skin irritation, a pill you keep forgetting, a vaginal product that’s uncomfortable — these are real reasons to ask about a different route. The best regimen is one you’ll actually use.
What did The HRT Index verify for this guide?
Read our full verification standard
What we verified:the systemic vs local categories; the lining-protection logic, including the FDA-approved conjugated estrogens/bazedoxifene option; route-level trade-offs; cyclic vs continuous terminology; the FDA-approved vs compounded distinction and the FDA’s estriol position; the scope of the February 2026 label changes; and the current FDA-approved non-hormonal options, including Veozah’s boxed warning.
What we did not verify:your eligibility, your diagnosis, a safe dose for you, whether a specific product fits one person, or any provider’s current formulary beyond the dated, provider-stated examples noted above.
Who made it:The HRT Index Editorial Team. We did not add a clinician’s name or a “medically reviewed by” badge, because no clinician reviewed this specific page, and we won’t pretend otherwise.
For how we review providers specifically, see The HRT Index Verification Standard. Read our affiliate disclosure, privacy policy, and editorial team.
What should I ask at my first HRT consultation?
A good consultation connects your most disruptive symptoms to your uterus and surgical history, your bleeding pattern, your contraception needs, your risk history, your route preferences, and your coverage. The goal isn’t to demand a specific dose — it’s to make sure your clinician explains why the category and route they’re recommending fit you.
Print this. Bring it. It turns a rushed visit into a real conversation.
- Are my symptoms mostly whole-body, mostly local, or both?
- Do I need lining protection with what you’re recommending — and how (a progestogen, the conjugated estrogens/bazedoxifene combination, or another strategy)?
- Is the estrogen oral, transdermal, or local — and why that route for me?
- Is this medication FDA-approved or compounded?
- What’s the exact medication name?
- What should improve first, and roughly when should we reassess?
- Which side effects or bleeding changes should I report right away?
- What happens if the first route doesn’t fit my routine?
- Does this treatment also prevent pregnancy? (Menopausal hormone therapy itself does not; a separate method or component may.)
- What would make you recommend in-person or specialist care instead?
- What will the medication and follow-up cost, and is it covered by my insurance?
- How do I reach the care team between visits?
You’re not failing to understand something obvious
If this felt harder than it should be, that’s not on you. The labels overlap because they describe different parts of the same decision— and many sources explain the words without ever showing you how they fit together. “Estrogen-only vs combined” is your uterus. “Patch vs pill” is route. “Bioidentical vs compounded” is regulation. They were never competing answers to one question.
Your job before a consult isn’t to choose a medicine from a list. It’s to know which questions need answers. You’re there now.
Still not sure which HRT program is right for you?
Take our free matching quiz. It turns your situation into a focused plan — and tells you honestly when online care isn’t where you should start. Educational guidance only. No email required. Your answers don’t create a diagnosis or a prescription.
Find your personalized HRT path →Frequently asked questions about the kinds of HRT for menopause
What are the two main kinds of HRT?
The two main categories are whole-body (systemic) therapy and low-dose vaginal (local) therapy. Systemic therapy treats body-wide symptoms like hot flashes; low-dose vaginal therapy treats vaginal and some urinary symptoms with very little hormone reaching the rest of the body.
Which kind of HRT is best for hot flashes and night sweats?
Whole-body (systemic) estrogen is the category usually discussed for moderate-to-severe hot flashes and night sweats. Whether it is a pill or a transdermal patch or gel, and whether you also need lining protection, depends on your individual situation.
Which kind of HRT is used for vaginal dryness or painful sex?
Low-dose vaginal (local) estrogen is the usual category for vaginal dryness, burning, and painful sex. It comes as a cream, tablet, insert, or low-dose ring, and very little hormone enters the bloodstream.
Do I need progesterone if I have a uterus?
If you have a uterus and use systemic estrogen, you generally need lining protection — usually a progestogen, or in one FDA-approved regimen, bazedoxifene combined with conjugated estrogens. Your clinician should explain which strategy they are using and why.
Do I need progesterone with low-dose vaginal estrogen?
Routine progestogen is generally not recommended with standard low-dose vaginal estrogen. Report any bleeding to the prescribing clinician, and note that long-term endometrial-safety data beyond one year are limited.
Do I need progesterone after a hysterectomy?
Many women without a uterus use estrogen alone, because there is no lining to protect. Still, your reason for surgery and your full history should be confirmed before turning that general rule into a treatment plan.
Is a patch safer than an estrogen pill?
Oral estrogen is associated with higher blood-clot risk than transdermal estrogen (patch, gel, spray), because the pill passes through the liver first. Safer depends on your specific history, and a patch lowers risk rather than removing it.
Can I take HRT while I still have periods?
HRT can be discussed during perimenopause, but your bleeding pattern and contraception needs affect the plan. Menopausal hormone therapy itself does not provide contraception, since pregnancy is still possible until menopause is confirmed.
Is cyclic or continuous HRT better?
Neither is universally better. Cyclic HRT is common while periods continue and usually causes a scheduled withdrawal bleed; continuous-combined HRT is common after menopause and aims for no scheduled bleed. Bleeding pattern, tolerance, and preference guide the choice.
Is bioidentical HRT FDA-approved?
Some bioidentical hormones are FDA-approved, including estradiol and micronized progesterone. Bioidentical describes chemistry, not approval status, so you have to check the exact product.
Is compounded HRT the same as FDA-approved HRT?
No. Compounded hormones are made per prescription and are not FDA-approved as finished products, and the FDA does not have evidence that compounded bioidentical hormones are safer or more effective than FDA-approved therapy. A documented clinical need can justify compounding, but it is not the default.
Is estriol FDA-approved?
No. There are no FDA-approved drugs containing estriol, and estriol appears in some compounded bi-est formulas. The FDA has stated it does not have evidence that estriol is safe and effective or a safer form of estrogen.
Do I need blood tests before starting HRT?
Often a single hormone level does not choose your HRT, because levels fluctuate during perimenopause. A clinician may still order tests when the diagnosis is uncertain, menopause is unusually early, pregnancy is possible, or another condition needs ruling out.
What about testosterone for menopause?
For women, the only evidence-based use is treating distressing low sexual desire (HSDD) in postmenopausal women, prescribed off-label since no female testosterone product is FDA-approved. It may be used with or without estrogen, it is not a routine treatment for energy or weight, and it is a Schedule III controlled substance requiring proper oversight.
Can I start systemic HRT after age 60?
Starting systemic HRT after 60 or more than 10 years after menopause is not automatically off the table, but it calls for a more individualized look at your symptoms and absolute risks. The benefit-risk balance is generally most favorable when systemic HRT starts before 60 or within 10 years of menopause, and this timing framework applies to systemic therapy rather than low-dose local vaginal estrogen.
How long can I stay on HRT?
There is no universal stop date. Continued systemic menopausal hormone therapy should be reevaluated periodically based on symptoms, benefits, risks, dose, route, and your preferences; age alone is not a mandatory stopping rule.
Can an online HRT clinic handle every case?
No. Straightforward menopause care may be appropriate online, but unexplained bleeding, major risk histories, uncertain diagnoses, or situations needing an exam may belong in person first.
The HRT Index is an independent decision resource for online menopause and HRT care. This page is educational and is not individualized medical advice; it was not medically reviewed by a clinician. FDA-approved and compounded options are labeled distinctly throughout, and compounded products are never presented as safer than, more natural than, or equivalent to FDA-approved medication.
Affiliate disclosure: As of June 2026, this page contains no provider affiliate links. The providers named appear only as factual, dated examples to illustrate where each category of care is available.
Sources
FDA, Menopause (consumer health page); FDA, “FDA Approves Labeling Changes to Menopausal Hormone Therapy Products” (Feb 12, 2026); HHS/FDA boxed-warning fact sheet (Nov 2025); FDA Drug Safety Communication for Veozah (fezolinetant), Dec 2024; FDA approvals for Brisdelle (2013), Veozah (2023), and Lynkuet / elinzanetant (Oct 24, 2025); Duavee (conjugated estrogens/bazedoxifene) FDA prescribing information; The Menopause Society, 2022 Hormone Therapy Position Statement; ACOG, Compounded Bioidentical Menopausal Hormone Therapy (Clinical Consensus, 2023); Global Consensus Position Statement on the Use of Testosterone Therapy for Women (2019); NHS, Types of HRT; peer-reviewed VTE/route literature including Circulation 2007 and NICE 2024 guidance; provider facts from joinmidi.com and bywinona.com (provider-stated, checked June 2026).