HRT gel: how it works and how to use it well

How it works

Like a patch, gel takes the transdermal route. The oestrogen passes through the skin and into the bloodstream directly, rather than being absorbed through the gut and passing through the liver first.

That matters clinically. UK guidance recommends transdermal delivery for women at increased risk of blood clots, including women with a BMI over 30, because it is not associated with the clot risk seen with oral oestrogen. Gel and patches share that advantage.

How it is applied

Once daily, to clean dry skin, usually on the arms, shoulders or thighs. Spread over a wide area rather than concentrating it.

Practical points that matter more than they sound:

• Let it dry fully, usually two to five minutes, before dressing.
• Wash your hands afterwards. Oestrogen gel transfers by skin contact, and transfer to a partner or a child is a genuine risk, not a theoretical one. Avoid skin-to-skin contact at the application site until it is dry and preferably for an hour.
• Not on the breasts or on broken skin.
• Do not apply immediately before swimming or showering.
• Avoid sun cream at the same site and time, which can affect absorption.

Gel or patch

Gel suits you if you dislike visible adhesive, you have had skin reactions to patches, you want fine control over dose adjustment, or you live somewhere hot where patches lift.

A patch suits you if you would rather think about it twice a week than every day, you do not want to wait for something to dry each morning, or transfer risk is a concern because of small children.

Both deliver steady levels and both avoid the oral clot risk. Neither is clinically superior in general; they suit different lives.

Progesterone still applies

Gel is oestrogen only. If you have a womb you need progesterone alongside it to protect the womb lining, usually as a capsule. This is not optional whichever oestrogen format you use.

Side effects

Shared with other oestrogen formats: breast tenderness, headaches, nausea and some irregular bleeding are common in the first three months and usually settle.

Specific to gel: skin irritation at the application site, and the transfer risk above.

Signs to report rather than wait out: calf pain or swelling, breathlessness, chest pain, severe headache, or significant unexpected bleeding.

What about spray?

Oestrogen spray works on the same principle, applied to the forearm daily. The considerations are broadly the same as gel, including drying time and transfer.

What we prescribe, and why it may not matter

fira prescribes body-identical HRT as patches or capsules, with progesterone where you have a womb, and vaginal oestrogen where it is needed.

If your clinician thinks a format we do not offer is the right one for you, they will say so. That is the point of an assessment rather than a menu: the plan should follow your history, and being told the honest answer is worth more than being sold the available one.