Patches, Pellets and Progesterone: A Real Guide to HRT Options

I talked with Christa Biegler on The Less Stressed Life podcast about something patients ask me constantly. What are my actual options for hormone replacement, and how do I pick the right one? There's no single answer, so I wanted to walk through how I actually think about it.

Perimenopause Is the Second Puberty

By your mid thirties, your egg supply has already dropped to around 10 percent of where you started. Your eggs get lazy, and the communication between your brain and your ovaries starts to break down. Progesterone usually declines first, which is why so many women notice heavier cycles and worse PMS before anything else changes. I call this the second puberty, because your body is going through a hormonal shift just as dramatic as the first one, just in reverse.

What I Check Before I Even Talk About Hormones

Are you pooping every day? Are you detoxifying? Are you moving your body? Are you sweating? Before I add a single hormone, I want to know your gut health is solid, your thyroid is functioning well, your adrenals are supported, and your micronutrients, things like B12, folate, vitamin D, and iron, are where they should be. Hormones don't work well on a shaky foundation.

Your Estrogen Options

Patches, gels and creams, oral tablets, pellets, and vaginal estriol are all real options, and none of them are automatically right or wrong. I usually prefer a twice weekly patch over a once weekly one for more reliable adhesion. Oral tablets carry a slightly higher blood clot risk because they're metabolized through the liver. Pellets last three to four months but give you less ability to adjust the dose if something isn't working. Vaginal estriol has very low systemic absorption and is worth considering even if you're already on a systemic option, because of what it does for tissue health.

Progesterone Isn't One Size Fits All Either

Immediate release progesterone can help with sleep and anxiety because of a metabolite it produces, but if that metabolite doesn't agree with you, a sustained release compounded version, or a vaginal or rectal option that bypasses the liver, might work better. This is exactly why I introduce hormones one at a time when I can. If something doesn't sit well with you, I want to know which one it was.

Testosterone Has More Safety Data Than People Realize

Compounded cream, weekly injections, and pellets are all options for testosterone in women, and we actually have around 30 years of safety data on testosterone use at higher doses, from trans men, that gives us real confidence in how it behaves.

Why I Watch Symptoms as Much as Labs

I test serum hormones because it's more practical and cost effective for most patients than something like DUTCH testing, which can take months to turn around. But I don't just chase numbers. In perimenopause especially, I'm trying to provide a safety net so you don't bottom out, and that means adjusting based on how you actually feel, not just what a lab says. You lose more bone in the first two years of these hormonal declines than almost any other time, so waiting until labs look perfect isn't always the right call.

This is the infancy of hormone replacement, even though I feel like I've been doing it forever.

One Patient's Story

I had a 51 year old patient on birth control who came in with fatigue, depression, anxiety, and joint stiffness. No hot flashes, nothing that screamed menopause. That's exactly the kind of case that gets missed, misdiagnosed as a thyroid problem, a psychiatric issue, or an autoimmune condition, when it's actually hormonal.

If it doesn't sit well with you, listen to your body, pay attention, and write your symptoms down. You can hear this entire conversation, Patches, Pellets and Progesterone: A Complete Guide to HRT Options, on The Less Stressed Life podcast with Christa Biegler at https://youtu.be/HMoeLj3OaF0. If you want help figuring out which option is actually right for you, reach out.