A Reader Asks, Part Two: How Do You Choose a Delivery Method?

Written by: Meredith Paci Functional Health Coach

This is part two. There is a two-part series here answering a reader question submitted through our anonymous form. If you have not read part one, [it's linked here]. It discusses the nuts and bolts of evidence on estradiol, progesterone, and testosterone, what is well supported versus overstated, and what her specific situation, a woman between 36 and 40, cycling consistently, no hormone therapy, has had labs, does and does not tell us about whether hormone therapy is even the right next step for her right now.

This post picks up where that one left off. Her second question was about delivery methods. How do you actually choose one, and does it matter which you pick?

It matters quite a bit, and this is a conversation that deserves more than a list, because the method you use changes the hormone's behavior in the body, not just its route of entry.

That said, this is not a decision you make alone and depending on your location you may be limited to specific forms...this is not necessarily 'bad' but it is a thing. This is where having a well educated provider who knows your full medical history is incredibly important, because the right choice depends on your health, your risk factors, sometimes your own comfort level, your habits/lifestyle and dare I also say what will be done consistently. An injectable form, for example, would not be appropriate for someone with a genuine needle phobia, no matter how clinically sound it is on paper.

Before I get into specific modes, I want to circle back to something I mentioned just above briefly. Within every form I'm about to describe, there are more nuances than I can cover in one post. And one of those nuances is YOU individually. That said, depending on what country or even what state you're in, availability and what's typically suggested can vary. Provider comfort and experience with a given method matters too. So what follows is a accurate but broad-strokes look at the major categories. If you want me to go deeper on one specifically, that's exactly what the anonymous form is for! You can submit a question.   HERE

Oral

Let's start with the obvious: oral means a pill. I want to say that plainly because "oral" gets used loosely, and there are other oral-adjacent options out there, including liposomal hormone preparations. I'll mention them here, while also being clear that liposomal delivery is not generally considered an efficacious route.

Oral estrogen undergoes first-pass liver metabolism, which can change its effects on clotting factors, triglycerides, and sex hormone binding globulin. I want to be thoughtful here: this does carry an increased clotting risk specifically because of that first pass through the liver, but I'm cautious about saying it's universally "not the preferred route," because for some women it may genuinely be the more appropriate or practical choice. An elderly woman who isn't able to self-administer an injection is one example where oral might make more sense than the alternative. Individuality matters here as much as anywhere else in this conversation. Where I would be more cautious is in a woman with significant cardiovascular risk factors or active cardiovascular disease, where this route may not be the best fit.

Oral micronized progesterone, brand name Prometrium, is commonly used and does not carry that same metabolism concern. In fact, the target effects, including the sleep and calming benefits through its conversion to allopregnanolone, are actually supported by taking it orally.

Troches

Troches are another route. They sit somewhere between oral and oral-adjacent. A troche is a compounded lozenge that dissolves in the mouth, typically held against the cheek or under the tongue, and absorbed through the oral mucosa rather than swallowed and processed through the digestive tract and liver in the exact same way a standard pill is. Because of that, troches are said to bypass first-pass liver metabolism, similar to transdermal routes. In practice, absorption with troches can be inconsistent: how long someone holds it, where in the mouth, whether they eat or drink shortly after, all of this affects how much hormone actually gets absorbed. That said, this is typically discussed with thorough instructions with the patient. This is a compounded product, so it is only available through a compounding pharmacy and only with a provider's prescription, not something available over the counter.

Transdermal: Patches, Gels, Creams

Transdermal estradiol bypasses first-pass liver metabolism, which is why it is the preferred delivery method for estradiol in most clinical scenarios. It produces more stable serum levels than oral and does not carry the same clotting risk. Patches, applied twice weekly or weekly depending on the product, offer consistency. Gels and sprays offer dose flexibility but introduce absorption variability depending on application site, skin thickness, and individual absorption capacity.

Transdermal progesterone creams are a separate conversation, and one that gets glossed over frequently. Topical progesterone does not reliably raise serum progesterone enough in many women to be considered adequate uterine protection. I also want to flag that topical progesterone cream is typically available over the counter, and in my professional and personal opinion, buying hormones over the counter without guidance is not appropriate or safe.

If a woman with a uterus is using estradiol and relying on a topical progesterone cream for uterine protection, she may not actually be as protected as she thinks. To be clear about what I mean by that: I'm not suggesting she will automatically develop cancer. The point is that estradiol is proliferative, which is a normal and necessary part of what it does, until it isn't appropriately balanced. Oral micronized progesterone and vaginal progesterone are the routes with documented uterine lining protection.

Transdermal testosterone cream exists and is used. Absorption variability is higher than with injectable testosterone, and cream can transfer to partners or children through skin contact if not managed carefully.

Injectable

Injectable estradiol, typically estradiol cypionate or valerate, and injectable testosterone cypionate are administered subcutaneously or intramuscularly. The schedule varies, weekly, biweekly, sometimes a few times per week depending on the protocol, but it is essentially never daily and never monthly. They are effective, they produce predictable pharmacokinetics, and they are titratable. If a dose needs adjusting, you adjust the next injection.

Injectable testosterone for women uses a MUCH lower concentration than what is manufactured for men. Standard testosterone cypionate comes at 200 milligrams per milliliter, built for male dosing protocols. For women, compounding pharmacies typically prepare it at a significantly lower concentration so the small weekly amounts women actually use can be measured accurately. I'm not giving specific milligram targets here on purpose. This is not something to self-determine or self-dose. It's a conversation to have directly with your prescribing provider. 

The capacity to titrate to the lowest effective dose is a clinical advantage that pellets, which we'll get into next, do not offer.

I want to be direct here, and I'll say plainly that this next part is my own opinion. Injectables are underutilized in the women's hormone therapy conversation. The case for them rests on dosing precision and predictability, which is well understood pharmacologically. What's thinner is direct comparative research on delivery methods specifically, meaning head-to-head data on outcomes by route. So part of why injectables come up less is genuinely that this corner of the evidence base is still developing. But a meaningful part of it is also practical: injectables require patient comfort with self-injection and more active monitoring, versus a method where you set it and forget it. That second part is a practical barrier, not a clinical one, and it deserves to be named as exactly that.

And because I just can't help myself let me also state this plainly: NO, YOU CAN NOT JUST USE YOUR HUSBANDS TESTOSTERONE to save money. Do not do it! 

Pellets

Subcutaneous pellets, about the size of a grain of rice, are inserted into the hip or gluteal area and release hormones over the following months.

I want to be transparent that I have a bias here, and I am not a fan of pellets. That said, I don't think they're inappropriate for every single person. There may be a specific situation where they make sense for someone. What I will say plainly is that dosing with pellets cannot be as precise once they're in, and women are routinely overdosed. This often becomes a set-it-and-forget-it pattern, where someone comes in every twelve to sixteen weeks the way they'd book a haircut, with no real monitoring in between. In the testosterone space specifically, pellet-driven supraphysiologic levels are common, and the associated risks, including androgenic side effects, elevated hematocrit, and SHBG suppression, are real.

I want to be clear that this is my own opinion. I do not typically suggest pellets as a first choice in most cases. In fact, I have not yet recommended them at all.

Vaginal

Local vaginal delivery, in cream, ring, or suppository form, includes estradiol and is also where DHEA comes into the conversation. Progesterone has a role here too. These are used primarily for genitourinary symptoms without 'meaningful' systemic absorption at low doses (I did not say no systemic affect). This route is appropriate for women who have localized symptoms and who are not candidates for or not interested in systemic therapy. It does not provide the cardiovascular, bone, or brain benefits associated with systemic estradiol, because it is not designed to.

Back to Her

Now back to the woman who actually asked the question.

We established in part one that her situation does not yet have enough information behind it to determine whether hormone therapy is the right next step at all. That has not changed. What this piece adds is that even once that determination is made, for her or for anyone in a similar position, the delivery method conversation is not an afterthought.

If progesterone support becomes relevant for her, oral micronized progesterone, not a cream, is the likely route with actual evidence behind it for sleep and mood support, and the only route with documented uterine protection if estradiol is also part of the plan.

If testosterone becomes relevant, the conversation, with a provider, will likely start with injectable, low dose, titratable, not a pellet. The convenience of a pellet is not worth the loss of dose control, and the risk of overshooting into supraphysiologic territory is real and well documented. That said, the conversation could also start with a cream or even a troche and be a very viable option for her depending.

If estradiol becomes relevant, hearing she is still cycling leaves this a bit open as merely just menstruating does not really say where we are at regarding levels or protection. That said, with what I do know I'd say this would likely be the last intervention at this time if at all. 

None of this changes the answer to her first question. It just means that if and when the answer becomes yes, the next decision is not a small one, and it should not only be made based on what is most convenient to administer, but that is very important!

If you have a question of your own, the anonymous form that started this entire series is still open. [Ask Fortify here.] I already have the next one queued up and I cannot wait to get into it!

Meredith Paci is the co-founder of Fortify Health Coaching. I want to be clear that I'm not a licensed medical provider. The content in this post is educational and does not constitute medical advice or a patient-provider relationship. If you are considering hormone therapy, work with a qualified and well experienced provider who will assess your individual history.