Gel, patch or spray? Understanding transdermal HRT and why one size doesn’t fit all

Menopause
Written By Georgina Standen

Many women are told they are “already on a good dose” of HRT, yet still feel exhausted, anxious, foggy, achy or unable to sleep. When that happens, it’s easy to start wondering whether HRT has stopped working, whether symptoms are psychological, or whether this is just something to endure.

In reality, it’s often much simpler than that.

Not all HRT is absorbed in the same way, and not all bodies respond the same way to the same preparation. Understanding the differences between gel, patch and spray can be an important step in finding the treatment that actually works for you.

At Sirona Health, we see this every day.

What does “transdermal” HRT mean?

Transdermal HRT means oestrogen is absorbed through the skin rather than swallowed as a tablet. This avoids first-pass metabolism through the liver and gives steadier hormone delivery for many women and is recommended by UK guidelines.

Transdermal oestrogen is available in three main forms:
• gel
• patch
• spray

All three contain the same hormone, estradiol, but how your body absorbs it can differ significantly.

Estradiol gel: flexible but variable

Estradiol gel is applied once daily, usually to the thighs or upper arms. After application, the hormone is absorbed through the skin into the bloodstream.

Blood levels tend to rise gradually, reaching their highest point a few hours after application, and then remain fairly stable over 24 hours when used consistently. After several days of daily use, levels generally stabilise.

For many women, gel works very well. It’s flexible, easy to adjust, and well tolerated.

However, studies consistently show large differences between women in how much estradiol is absorbed from gel. Two women using the same number of pumps can end up with very different hormone levels. Even the same woman may absorb it differently at different times of year, or after changes in skin condition, circulation, or application site.

This means that symptoms returning on gel does not automatically mean you need more oestrogen. Sometimes it means your body is simply not absorbing that preparation as effectively anymore.

Estradiol patches: steadier delivery, different challenges

Patches deliver estradiol continuously over several days and are applied to the lower abdomen, buttock or upper arm.

Because the hormone is released steadily, patches often produce more even blood levels than gel, particularly mid-wear. Some women feel more stable on patches, especially if they are sensitive to hormonal fluctuations.

That said, patches also show variability. Levels can be lower at the beginning and end of the wear cycle, and absorption can be affected by where the patch is placed, how well it adheres, skin temperature, and individual skin differences.

Some women thrive on patches. Others find they don’t absorb them well or experience skin irritation.

Estradiol spray: a newer option

Estradiol spray is applied as a fine mist to the skin, usually the inner arm. It dries quickly and delivers a measured dose with each spray.

Clinical studies and real-world use show that spray can be effective for menopausal symptoms and well tolerated. It can be particularly useful for women who struggle with gel absorption or dislike patches.

As with gel and patches, absorption still varies between individuals. Spray isn’t “stronger” or “weaker” as a rule; it’s simply another way of delivering the same hormone, and sometimes it’s the delivery method rather than the dose that makes the difference.

Where and when you apply HRT matters

Across all transdermal preparations, application technique matters more than many people realise.

Absorption is influenced by:
• site of application
• skin thickness and hydration
• circulation
• consistency of timing
• allowing the product to dry fully
• avoiding skin-to-skin contact with others for at least an hour

These factors help explain why someone may feel well for months and then notice symptoms creeping back without any change in dose.

Why blood tests don’t tell the whole story

You may have been told that blood tests aren’t helpful in menopause, or that your level is “normal”.

The truth is more nuanced.

Serum estradiol testing does not tell us what level you “should” be at. There is no target number that guarantees symptom relief. However, blood tests can sometimes help us understand whether a preparation is being absorbed at all, particularly if symptoms persist at higher doses.

What they cannot do is replace listening to how you feel.

At Sirona Health, we use blood tests selectively and thoughtfully, alongside a detailed symptom review, not as a pass-fail test of whether HRT is working.

Why symptoms can return even on “high doses”

When symptoms come back, it is rarely because a woman has suddenly become “too anxious” or “too sensitive”.

Common reasons include:
• changes in absorption of transdermal oestrogen
• intolerance to progesterone rather than lack of oestrogen
• the need to change formulation rather than increase dose
• the impact of sleep disruption becoming self-perpetuating
• overlooked androgen (testosterone) deficiency

Simply increasing oestrogen is not always the answer, and sometimes won’t help at all unless the underlying issue is addressed.

How we approach this at Sirona Health

We don’t believe in chasing numbers or endlessly escalating doses without a plan.

Instead, we focus on:
• understanding your symptom pattern
• reviewing how and where your HRT is applied
• considering whether a different transdermal preparation would suit your body better
• reviewing progesterone carefully, as it is a common cause of sleep and mood symptoms
• considering testosterone where appropriate
• supporting sleep and nervous system regulation alongside hormones

This is why many women come to us after being told they are already “on the maximum” and finally start to feel like themselves again.

If you’re still symptomatic, you’re not failing HRT

You are not difficult.
You are not imagining it.
And you are not out of options.

Often, it’s not about more hormone, but about the right hormone, in the right form, for your body.

If you’d like personalised, evidence-based support to get this right, you can book a consultation with Sirona Health below.

FAQ

  • No. They all deliver estradiol. The difference lies in how your body absorbs them.

  • Blood levels usually stabilise within a few days of consistent use, but symptoms can take several weeks to improve.

  • Not always. A change in formulation or progesterone adjustment is often more effective.

  • Progesterone intolerance is common and can affect sleep, mood and cognition.

  • Not routinely, but they can be useful in specific situations to assess absorption.