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There are multiple HRT options for women.  It can get confusing when you first try to decide which type of HRT to take.  Below we will list and explain the different options and how they work.


Oral Estrogen:

The first option is oral pills.  Pills are one of the oldest and most prescribed methods of taking HRT.  Many doctors are now finding other means of HRT more appealing, as the oral pills cause what we call, a first pass liver effect.  What that means is, that when you take the pill, the medication first has to get processed by the liver.  The liver will end up decreasing the amount of medication in an attempt to correct what the body sees as an assault on it’s well being.  This effect usually means that oral doses need to be higher than transdermal doses, so that more of the medication can make it past the liver for circulation.  This can be hard on the stomach, gallbladder and liver.  It also raises the the proteins called Sex Hormone Binding Globulin (SHBG).  These proteins are capable of inactivating hormones in the body like estrogen and thyroid hormones.  Oral estrogen is also capable of raising the body’s C Reactive Protein, which is responsible for inflammation and increased risk of stroke and blood clots.  Oral estrogens aren’t all bad though.  Oral estrogen has the unique capability of lowering cholesterol, and the the medication is usually the cheapest of all the options out there.  Some ladies find the oral option matches well with their body.


Transdermal Estrogen:

Transdermal estrogens are estrogens applied to the skin.  This does not include vaginal or transbuccal deliveries as those use the mucosal tissues.  Transdermal estrogen is applied to the skin and creates a pool of hormones in the skin layer or fat layer and releases the hormones from there.  Creams, gels, and patches are all considered transdermal, but each of them act differently when applied to the skin.


Gels: Gels are usually absorbed faster and create a cache in the skin layer and are quickly absorbed into circulation.  This top layer mechanism makes the gels more susceptible to being transferred accidentally to children, pets or spouses if the waiting period for absorption is not followed.  Clothing covering the area after dried can prevent some of this rub off.  Gels are also easily sweated off during hot weather or increased activity.


Creams: Creams absorb down beneath the skin into the fat layer underneath.  This allows the hormones to create a pool of medication in the fat layer and it slowly releases the hormones into circulation.  After applying the cream, time is needed to let it absorb before letting that area of skin come into contact with others (usually 1-2 hours).  The ability of the creams to absorb into the fat layer can sometimes cause problems when the amount of hormones build up to an uncomfortable level. 


Patches: Patches are small sticker type delivery systems that can be attached to the skin on the abdomen, hips or upper buttocks.  However, it has been shown that patches applied on the backside area provide a 20% higher absorption than patches attached to the abdomen.  Patches are a good choice for women who want a slow, consistent, trickle dose of hormones.  This provides more stability and less hormone swings than some other options of hormone deliveries. 


All transdermal doses are easily changed by altering the amounts applied.  This feature, plus the positive of bypassing the liver absorption, makes them one of the top used methods today.  Due to it’s unique ability to avoid the liver, transdermal options are considered safer for women with risk factors such as blood clots, smoking, or liver-related diseases.  However, all transdermal estrogens are affected by heat.  Whether it’s heat from the summer months, heat during the shipping process, or even heat during baths or exercise, it’s important to keep in mind that temperature changes can affect the time release and stability of the dose.


Overall, transdermal estrogens are considered a safe and effective way for women to replace lost hormones.


Transbuccal and Mucosal Estrogens:

There is a not so well known application of estrogen called transbuccal or mucosal dosing.  This application of estrogen is done by using the mucosal tissues in the mouth or vaginal area.  Estrogen used this way can be in the form of drops, troches (wax melts dissolved in the mouth), pills dissolved in the mouth, or creams and gels applied to the vaginal tissue areas.  These type of applications also share the benefit of avoiding the liver, and they also have a reputation of having a very strong absorption rate.  Because this type of dosing is not applied over the skin, the uptake is much quicker and enters circulation faster.  This can be a desirable effect for some women who have had a hard time getting enough hormones in, but it can have a quick uptake and a quick decrease in between doses which can cause a bit steeper rise and fall of hormone levels.  These fluctuation will be more pronounced than the transdermal dosing options and may be problematic for some ladies. 


Subdermal Estrogens:

Subdermal estrogens are basically estrogens that are applied beneath the skin. There are two different options for doing this:  One is an estrogen shot, and the other is a pellet inserted under the skin.  Both have the advantages of a slower, more even release over months.  However, the downside is that, once inserted, the level can not be adjusted or changed until the hormones wear off.  Usually this type of dosing is done every 3 months or so, depending on how fast your body absorbs and utilizes the hormones.  This type of dosing can be very beneficial for women who have struggled to get an even dosing of hormones.  Many women choose to wait until they have a good idea of what their optimal hormone levels should be before trying this method of dosing.


Vaginal Rings:

Vaginal hormone rings are one of those hormone applications that doesn’t fall squarely into one category or another.  It’s most like transdermal dosing as it is slow and time released.  The Estring vaginal ring is meant only vaginal dryness and stays local in the vaginal tissues.  It does not tend to provide enough estrogen to help the body overall.  The other vaginal ring, Femring, is meant for total systemic hormone replacement, and can help with menopausal symptoms.  Some women really enjoy the slow 3 month long release and steady levels.  However, there have been reports of ladies struggling to get them to last for the entire 3 months and having them run out much earlier than they should.  Also some cramping while using the vaginal rings has been noted as a common side effect. 


As you can see, there are multiple ways to dose your HRT.  Each method works for certain ladies and not as well for others.  This is why hormone balancing is so individual and specific to your body type and activity level.  Some ladies find their match right away, while some other women need to try a few methods before they find something that is a good fit.  So, if one method isn’t working for you, give another one a try.

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