Estrogen gel

Estrogen gel carries estradiol, one of the forms of estrogen your ovaries made before the menopause. You rub it into the skin and it passes into the bloodstream from there. The NHS website says most estrogen medicines use estradiol made from plants, identical to the body's own, and the Pakistan Menopause Society counts estradiol among the body-identical hormones (section 5.10).

It comes in a pump or in sachets. On its own it is estrogen-only HRT. If you still have your womb, Women's Health Concern says you also need a separate progestogen, such as micronised progesterone or the hormonal coil, to protect the womb lining.

It is not the same as vaginal estrogen, which the NHS website says helps vaginal dryness but does not treat hot flushes. Gel on the skin is whole-body HRT.

The routine is short. The NHS website describes it like this: clean, dry skin on the arms or lower body, as your leaflet says; rub the gel over a wide area; let it dry before you dress; leave that skin unwashed for the time the leaflet gives; wash your hands. Use a different patch of skin each time, and keep it away from the breasts and genitals.

Relief is not instant. The NHS website says HRT can take up to three months to work fully. Early side effects it lists include headaches, breast tenderness and some spotting, which often settle. A rash only where you apply the gel is worth telling your doctor about.

How it differs from tablets

The estrogen is the same. The route is different, and the guidance treats that as more than convenience. NICE NG23 says: "VTE risk is not increased with transdermal HRT." It also says stroke risk is unlikely to rise with estrogen through the skin, while tablets raise it.

The BMS HRT guide lists reasons a doctor may choose the skin route: your own preference, poor relief from tablets, a gut condition that affects absorption, a personal or family history of clots, a higher BMI, blood pressure that is hard to control, migraine, gallbladder disease, and some other medicines.

Why this matters for South Asian women

The BMS notes higher rates of metabolic syndrome, insulin resistance, diabetes, central weight gain and high blood pressure in South Asian women around the menopause. Several of those are on the PMS list of reasons to prefer the skin route (section 7.1.1).

NICE NG23 recommends offering HRT for hot flushes and night sweats (1.5.1), and the PMS recommendations call it the most effective first-line medicine for them in women who can take it (section 7.1.1). Gel is one way to take the estrogen part. Gel, patch or tablet is your doctor's call, made with your history in front of them.

If you are not feeling better after three months, the NHS website says your doctor may change the dose or the type.

Book a review if nothing has changed after three months, if a rash appears where you put the gel, or if heavy or unexpected bleeding starts after the first six months. The NHS website says pain, redness or swelling in one leg, usually the calf, needs a doctor's advice straight away, and a lump or other change in a breast needs a GP appointment. Chest pain with breathlessness, or sudden weakness in the face, arm or leg, needs emergency help.

Gel on the arms raises a question many women ask quietly: what about wudu? The NHS website says not to wash that skin for a while afterwards, and wudu washes the forearms. Whether gel on the skin affects wudu is a question for a qualified scholar. Which skin to use, and when to put it on around prayer times, is a practical question for whoever prescribes it, and one worth asking out loud.