How to apply HRT correctly – our menopause doctors have some great advice

It’s not at all uncommon for menopause specialists to deal with patients who complain they’re feeling off, despite being on HRT gel, cream, spray or patches.

The assumption is often that the dose isn’t strong enough. But, says Dr Shahzadi Harper, GP and Instagram’s The Perimenopause Doctor, there are important things to check off before upping the dose any of your HRT meds: “Before we increase them, we go back to basics. I ask patients what type of HRT they are on and to show me how and where they’re applying it.”

Are you using the most appropriate type of HRT?

As is the case with any medication, some women don’t absorb some topical HRT products (or any transdermal medication) as well as others. Many possible factors can play a role, says GP and menopause medic Dr Fionnuala Barton, including genetics, ethnicity, skin type, skin quality (how naturally hydrated or oily it is) and sensitivity.

“If you’re not absorbing one version of HRT well, instead of ramping up the dose, first consider a different type,” says Dr Harper. Basically, you need to find the best ‘HRT delivery system’ for your body. “For example, if you’re not a ‘patch absorber’, you may do better with a gel, spray or oral application, or vice versa. Trying this out is what I do in my practice to avoid high doses and to stay within guidelines for most women,” says Dr Harper.

Although, you will not have this option to ‘switch and try’ with testosterone for women, which so far only comes in cream and gel form (although a patch is being developed). The good news is, says Dr Barton, is that AndroFeme, a testosterone cream specially designed for women, is now licensed in the UK for hypo-active sexual desire disorder (ie a flagging libido). The bad news? Due to cost for the NHS, it’s still only available privately. Unlike gels designed for men (the only ones available on the NHS so far), you won’t have to ‘guesstimate’ your dose of 5g here, as this 50ml tube comes with a dosing syringe that lets you measure out the exact amount.

Are you applying your HRT correctly?

Besides finding the right product for you, you also need to use your HRT meds correctly. Incorrect application, causing topical products to not get the chance to absorb properly, can be an issue, says Dr Harper. For example, you might get dressed before your oestrogen gel is dry, meaning it comes off on your clothes. Or if a patch is applied to skin that is oily, it may slide off.  It’s also important to note that when we sweat, swim and use SPF in the same areas in which we apply our HRT, there’s even more margin for error.

“You want to ensure you’re getting the right dose, so you’re not wasting the prescription you’ve paid for, and also to maximise the gel or patch’s efficiency. Optimising your application technique may solve your issues with HRT and could prevent you from asking for a bigger dose unnecessarily,” says Dr Harper.

Or from unintentionally harming your pets: if you don’t let your gels dry properly or wash your hands, you could get some of it on your furry friends. “This is harmful as it can impact a pet’s hormone levels, so try to avoid inadvertent transfer or opt for patches,” says Dr Barton.

Making mistakes is easy, so Dr Harper has made the below video for Get The Gloss showing exactly how best to apply HRT. We’ve also listed the most useful HRT application tips.

How to apply HRT on sunny holidays and during the summer

• Wait an hour before sun cream

You can go out into the sun straight away after applying your gel or cream, but of course, you’ll be applying your sun cream too. “If you are applying any lotions on top of your HRT, leave it at least an hour,” says Dr Harper. “The manufacturers say there’s no interaction with sun cream, but sometimes the high alcohol content of sunscreen can impair the absorption of your HRT,” she adds. So keep the two an hour apart.

• Consider changing to a patch for summer

HRT patches need to be changed only every 3.5 days, they can be applied to your hip or bottom in a place under your swimwear that’s shielded from the sun. But will they survive the sea or pool? “In the past I’ve had a few women mention to me that their patches came off when they were swimming,” says Dr Harper, “but the manufacturers have improved the stickiness and I haven’t had a single patient report any problems recently.” If your patch does come off, stick another one on and re-start your three and a half days of wear count from then, she advises.

• Wait an hour before you swim

Wait at least an hour after application before going in the water.

• Consider switching to applying before bedtime

If you sweat a lot in summer, or you don’t need the hassle of waiting around after you apply topical oestrogen, switch to applying it at night.

• Keep testosterone for the morning

“Testosterone is meant to give you energy and improve your mojo and because of this, I would stick to the morning. It’s only a small amount on the inner wrist or hips,” says Dr Harper. Again, wait an hour before swimming or showering.

How to apply HRT correctly all year round

• Ensure the skin is well-exfoliated and free from oil

Dr Harper recommends using a body scrub to get rid of dry skin on your arms, bum or hips, which can hinder absorption. But keep it away from your HRT. “Don’t put HRT on straight after using an oily exfoliator or a moisturiser in the morning, wait until the end of the day.”

• Avoid ‘losing’ some of your dose on your hands

To prevent HRT gels from partly absorbing into your palms and getting lost when you wash your hands, there are some things you can do, says Dr Barton. “Manufacturers of oestrogen gel recommend spreading gel onto skin and allowing it to absorb, rather than vigorously rubbing it in. And you can avoid losing gel on the hands by using your forearm to spread the gel onto your thighs.” Lenzetto, an oestrogen spray should, not be rubbed in either.

• Wait at least an hour before putting anything wet on your skin

Whether that’s showering or body lotion, give your gel, cream or spray a chance to absorb properly.

• Avoid putting oestrogen gel on the upper arms if you have bumpy skin

If you have those keratosis pilaris (those annoying bumps on the back of your upper arms), apply your HRT elsewhere. Not only will the gel find it harder to soak in here but, Dr Harper points out, “those bumps are blocked sebaceous glands, so if you add a layer of gel, you could be making things worse.” Regular exfoliation should help clear them up.

• You can experiment with where you apply your HRT

There is no clinical evidence that topical HRT absorbs better in some parts of the body than others, nor that there are areas that should be avoided, “as the drugs have only been tested in the areas the drug companies have licensed (usually arms and legs),” says Dr Barton. That said, she says, our skin health and absorptive capacity will vary in different areas and from person so we will all have sites that work better than others. “I encourage patients to test out different areas”, she says. 

• Rotating application areas to avoid ‘immunity’ to HRT may work

“Developing resistance to HRT by sticking to one application area “has not been demonstrated in research but is something we see in clinical practice,” says Dr Barton. Theoretically the skin cells may adapt and build up ‘tolerance’, she says. Conversely however, “with Lenzetto spray in particular the recommendation is to apply to the same area every day in order to establish a ‘reservoir’ of hormone that is then released more steadily into the blood stream over time”.

• Poor circulation? Apply HRT straight after the shower

Especially in colder weather, our circulation can suffer, says Dr Harper. “I suggest tapping your arms, legs, or bum repeatedly just before you apply the gel as this will help improve circulation and so help absorption. Or apply it just after a shower, when your body is warm.”

• Let it dry properly – don’t get dressed for at least 3 minutes

HRT gels need three to five minutes to dry, so wait before getting dressed.

• Apply testosterone gel over as large an area as possible

Testosterone preparations can in some cases cause unwanted hair growth where you apply it: “Tostran gel appears to be worst for this, so you could consider changing to Testogel or AndroFeme if you have this issue,” suggests Dr Barton. Her tips to prevent hair growth in the first place are to “dilute” the direct effect on skin androgen receptors by spreading the gel thinly over a large area, to move the application site regularly, or to use the gel on areas of skin you may shave anyway, such as below the knees.

• Wait an hour before putting on leggings or tight jeans.

Otherwise, most of the good stuff will end up soaking into the fabric. If this means your life is made easier by evening application, just switch. “Find the time of day that best suits you and stick to it,” says Dr Harper.

• Split dose your gel

If you’re using more than two pumps of gel, split them up, says Dr Harper. For a four-pump regime, for example, “apply two on your arms and two on your legs. Don’t apply all four in the same place, as it’ll take ages to absorb. You might get impatient and end up putting on your clothes too quickly.”

• Take oral progesterone an hour before dinner if possible

Keeping to a routine also applies to oral progesterone, which should be taken either an hour before you eat or a couple of hours afterwards and taken at night because it can make you sleepy. Dr Harper recommends you take it before dinner if you eat late, in case you fall asleep before you have a chance to take your meds.

• If you suffer progesterone side effects, there is a new alternative

Some women cannot tolerate the most common progesterone capsules (Utrogestan and Gepetrix) because of side effects such bloating, fluid retention and acne. So Dr Barton is pleased with the recent licensing of Nalvee, a ‘body-similar’ new type of progesterone that doesn’t have these drawbacks and is also very effective at controlling and regulating heavy or irregular bleeds. It is available on the NHS in some localities, but not everywhere yet.

• Be militant about your HRT patch’s lifespan

“They must be re-applied every three and a half days, not every three and then every four days,” says Dr Harper. “Because by the time you get to the end of the fourth day, it’ll be falling off and there won’t be much left to absorb.” Put an alarm on your phone to remind you.

What if you feel your HRT still isn’t working properly?

If you’ve ticked all the boxes above, then it’s time to see your doctor for a review. “You may need a blood test, you may need a different dose, or you may need to change the preparation of the HRT, as not all suit everyone,” says Dr Harper.