Estradiol Patch vs Pill: Which HRT Is More Effective?

Hot flashes, night sweats, vaginal dryness, mood swings—fluctuating estrogen levels in perimenopause can bring a host of frustrating symptoms. If you’ve considered menopause hormone therapy (MHT)—also called hormone replacement therapy (HRT)—to ease the transition, you’ve probably come across two popular options: estradiol patches and pills.

Both options can help balance your hormones and ease menopause or perimenopause symptoms. Estradiol patches and pills deliver estrogen that is absorbed into your bloodstream and used throughout your body. And they do it equally well, says gynecologist Mary Farhi, M.D. 

“Efficacy is not the main difference between estradiol pills and patches,” Farhi says. The real difference comes down to risk and whether you prefer convenience or customization: estrogen patches deliver a steady dose with minimal hassle, while estrogen pills offer flexibility for fine-tuning.

About the Experts

Cielo Gnecco, M.D., FACOG, is an obstetrician and gynecologist with Orlando Health Women’s Institute Center for Obstetrics & Gynecology who specializes in menopause hormone therapy. 

Mary Farhi, M.D., is an integrative gynecologist and Menopause Society Certified Practitioner (MSCP) at Rush University Medical Center.

Estradiol as HRT During Perimenopause

Your ovaries make three types of estrogen, but estradiol is the most abundant during your reproductive years. The hormone regulates your period, supports heart and brain health, and helps maintain bone density (1).

As you enter perimenopause, estradiol starts to decline. Ovulation slows, periods become irregular, and your body struggles to convert other forms of estrogen into estradiol as efficiently as it did before. Eventually, these hormone fluctuations can lead to symptoms like bone loss, vaginal dryness, and low libido (2). 

That’s where estradiol hormone therapy—whether through a patch or pill—can help. (If you have a uterus, your doctor will also prescribe progesterone, as estrogen alone may increase the risk of uterine cancer, says gynecologist Cielo Gnecco, M.D.)

“Estrogen-based hormone therapy, if started within 10 years of menopause or before age 60, has many benefits for many women,” Farhi says. The benefits of estradiol therapy during menopause include (1):

• Easing hot flashes
• Preventing bone loss
• Combating vaginal dryness
• Improving mood and sleep
• Increasing sex drive
• Reducing brain fog
• Protecting against heart disease

Within a couple of weeks of starting the right dose of estradiol, you may have fewer hot flashes and night sweats, a higher libido, and sharper mental focus.

MORE MENOPAUSE HORMONE THERAPY

Why More Women Are on HRT for The Long Haul

The Pill or HRT: Which Is Better for Perimenopause Symptoms?

Key Differences: Estrogen Patch vs. Pill

Clinical trials show estrogen patches and pills are both effective at tackling perimenopause symptoms. The right choice often depends on your lifestyle, health history, and personal preferences. Here’s how they differ:

Absorption and delivery

Estradiol patches are small, adhesive squares you place on your waist or thigh. The estradiol is then absorbed through your skin and directly into your bloodstream, providing a continuous dose of estrogen. Gnecco says most of her menopause hormone therapy patients ask for estradiol patches since the stick-it-and-forget-it method is more convenient. 

In contrast, estradiol pills need to be taken daily. Your liver metabolizes the pills before the estrogen enters your bloodstream (3). This process, known as first-pass metabolism, can influence how the hormone is absorbed (4).

Dosing

Estradiol patches typically need to be changed once or twice a week, depending on the dosage. For example, the lowest dose (0.025 mg) is replaced weekly, while higher doses (between 0.0375 and 0.05) may require bi-weekly application. 

Estradiol pills are taken once a day, usually at the same time you take progesterone if you’ve been prescribed it, Gnecco says.

Hormone levels

Most people will typically see faster relief from the estradiol patch than the estradiol pill, although this varies for every woman (5). With estrogen pills, it takes around two weeks to start seeing benefits, Gnecco says.

While results might take longer for HRT pills, they offer an advantage when it comes to dose customization. That’s because the pills can be halved or doubled. However, Farhi and Gnecco say standard doses are fine for most women.  

Whether you prefer the convenience of an estrogen patch or the flexibility of a pill, Gnecco says to anticipate some trial and error as your doctor works with you to identify the correct HRT dose. 

“I always start with the lowest dose. If that helps, then that’s it. We stop right there,” Gnecco says. But if you’ve been on one dose for two to three weeks and your symptoms haven’t eased, your doctor may titrate your dose up and check back in another two to three weeks.

Side effects

Estrogen-based menopause hormone therapy—regardless of the method you use—can come with side effects such as headaches, breast tenderness, and mood changes (6). However, pills and patches have unique potential side effects.

Estradiol pill side effects include (7):

• Stomach cramps
• Nausea and vomiting
• Diarrhea
• Bloating

Estradiol patch side effects include (8):

• Allergic reaction to adhesive
• Skin redness and mild sensitivity
• Itching

Many side effects usually resolve on their own as your body gets used to the hormones. If they persist after several weeks, your doctor may adjust your dose or delivery method. 

Risks

The way your body processes estradiol can influence the risks associated with each delivery method. Pills, which have to pass through the liver before the hormone enters your bloodstream, come with higher potential risks.

When the liver processes estradiol, it can increase inflammatory markers, Farhi explains. This inflammation can increase your risk for deep vein thrombosis or blood clots in the legs or lungs (9).

A 2019 study highlighted the difference, finding that estrogen pills increased the risk of blood clots by 58 percent within the first 90 days (9). Transdermal estrogen, which includes patches and gels, didn’t increase blood clot risk at all.

Choosing Between Estradiol Patch vs Pill?

While no clinical trials have directly compared the efficacy of estradiol patches and pills, anecdotal evidence from doctors suggests the patch may have a slight edge. 

“In my practice, I’ve observed the patch being slightly more effective,” Gnecco says. “When you take a pill, it has to go through your liver to be metabolized—this can affect absorption.”

Both Gnecco and Farhi prescribe the estradiol patch more often than the pill due to its convenience and lower risk of blood clots. 

However, both doctors emphasize estradiol delivery methods and doses aren’t one-size-fits-all. Just because one treatment is usually the best option for most women doesn’t mean it’s best for all women. Your doctor will work with you to figure out which is best to safely treat your symptoms.