HRT not working? Why your menopause treatment may need a review
Started HRT but still not feeling like yourself? Or perhaps it worked brilliantly at first, only for the hot flushes, sleepless nights or other menopause symptoms to creep back in? It doesn't necessarily mean HRT isn't right for you. Your treatment may simply need reviewing.
Starting hormone replacement therapy (HRT) can feel like a big moment. Perhaps you've spent months wondering why you're exhausted, waking at 3am or struggling to concentrate. You finally speak to your GP, start HRT and wait to feel better.
And then… you don't. Or you feel somewhat better, but not as well as you'd hoped.
Perhaps the hot flushes have disappeared but you're still sleeping badly. Maybe HRT worked well for a year and suddenly some familiar symptoms have returned. Or perhaps you've developed headaches, breast tenderness or bleeding and you're wondering whether your prescription is actually right for you.
This is where an HRT review can be particularly important.
There are different types, doses and ways of taking HRT, and finding the treatment that works best for you can sometimes take time. Your needs can also change as you move through perimenopause and menopause.
So rather than assuming that HRT has “failed” or simply stopping it, it may be time to look again at the whole picture.
How long does HRT take to work?
If you've only recently started HRT, it may simply be too soon to judge.
Some women notice improvements in symptoms within days or weeks, but HRT can take up to three months to have its full effect. Side effects can also occur when you first start treatment and often settle during the first few months.
This is one reason your follow-up appointment matters.
NHS and British Menopause Society guidance recommends reviewing HRT around three months after starting treatment or changing your HRT. Once you are settled on treatment, it should usually be reviewed at least annually.
That first review isn't simply a box-ticking exercise. It is an opportunity to ask: What's better? What isn't? Have there been side effects? And is this still the most appropriate treatment for you?
What are the signs that my HRT might need reviewing?
There isn't one definitive sign that an HRT prescription needs changing. Menopause symptoms overlap with many other health and life issues, so treatment needs to be considered individually.
But there are several reasons it can be worth arranging a review.
Your menopause symptoms haven't improved: If you've been taking HRT correctly for around three months and menopausal symptoms are still troubling you, speak to your prescribing clinician. It doesn't necessarily mean HRT won't work for you. Your clinician may need to reconsider the dose, the type of HRT or how it is being taken.
You feel better – but not quite well: This is surprisingly important. You don't need to wait until you feel terrible before booking a follow-up. Perhaps your night sweats have stopped but poor sleep is still affecting your day. Maybe your physical symptoms are much better but you continue to experience low mood or anxiety. A review allows us to separate what may still be related to menopause from symptoms that could have another cause, rather than automatically assuming that more hormones are the answer.
Your symptoms have returned: Perimenopause isn't static. Your own ovarian hormone production can fluctuate and eventually decline, so a treatment that suited you at one point may need reconsidering later. A return of symptoms is therefore a reason for a review, not necessarily a reason to give up on HRT.
You're struggling with side effects: Headaches, breast tenderness, nausea, mood changes and unexpected bleeding can occur with HRT and often settle during the first few months. But persistent or troublesome side effects deserve attention. Sometimes changing the dose, preparation or way you take HRT can help. Unexpected vaginal bleeding also needs to be assessed appropriately. Some bleeding is common after starting or changing HRT, but you should seek medical advice if bleeding becomes heavy, persists beyond the expected settling period or occurs after you have been established without bleeding.
Why might an HRT prescription need changing?
Think of HRT less like buying the an off shelf pair of reading glasses and more like tailoring a suit. There are several elements that have to work together.
The dose may need reviewing. HRT is generally prescribed at the lowest effective dose needed to control symptoms. If symptoms remain troublesome, your clinician can assess whether a different dose is appropriate and safe.
The way you take it may need changing. Oestrogen can be given in different ways, including tablets, patches, gels and sprays. Your medical history, preferences, side effects and how you get on with a particular preparation can all influence which is most suitable.
Your progestogen may need reviewing. If you have a uterus and use systemic oestrogen, you will usually also need adequate progestogen to protect the lining of your womb. Different preparations and regimens can suit different women, and this part of the prescription is just as important as the oestrogen.
You may need additional treatment for vaginal or urinary symptoms. Vaginal dryness, discomfort during sex and some urinary symptoms may persist despite systemic HRT. Local vaginal oestrogen can sometimes be used alongside systemic HRT where appropriate.
Most importantly, the answer isn't always “more oestrogen”. If you are still struggling, a proper reassessment is safer and more useful than simply continuing to increase the dose.
What about testosterone?
Testosterone gets plenty of attention in conversations about menopause, but it isn't a universal missing ingredient.
Testosterone may be considered for women experiencing persistent low sexual desire associated with menopause when conventional HRT has not been sufficient and other possible contributing factors have been considered. It isn't routinely recommended simply to treat tiredness, low mood, brain fog or reduced energy.
If loss of sexual desire is affecting you, however, it is absolutely worth raising at your appointment. A menopause specialist can consider your symptoms in context and discuss whether testosterone might be appropriate.
Do I need a blood test to check whether my HRT is working?
Not always. For most women, HRT is adjusted according to symptoms and clinical response rather than aiming for a particular oestrogen number on a blood test. The British Menopause Society does not recommend routine serum oestradiol testing for women using HRT.
There are circumstances in which a clinician may decide investigations are appropriate, particularly if symptoms aren't behaving as expected or another medical condition is suspected.
Persistent fatigue, low mood, poor concentration or hair changes, for example, aren't exclusive to menopause. Depending on your symptoms and medical history, your doctor may consider whether something else, such as thyroid disease or anaemia, needs investigating.
That's another reason a good HRT review should involve more than asking how many pumps of gel you're using.
My GP prescribed my HRT. Can I still see a menopause specialist?
Absolutely. GPs manage menopause successfully for many women. But menopause treatment can become more complicated when symptoms persist, side effects develop, your medical history affects the available choices or it simply proves difficult to find a treatment that suits you.
Referral to a healthcare professional with menopause expertise may be appropriate when there is uncertainty about the most suitable management.
Seeing a menopause specialist doesn't mean starting again. Bring details of what you're currently taking, what you've tried previously and how your symptoms have changed. The aim is to understand what is and isn't working and decide what, if anything, should change.
Why your second HRT appointment can be as important as your first
Getting the first prescription can feel like the destination. In reality, it's often the beginning of the process.
At your follow-up appointment, we can look at:
Which symptoms have improved and which remain
Whether you are experiencing side effects
Any changes to bleeding
Whether you are using your HRT correctly and consistently
Whether the dose, formulation or regimen remains appropriate
Whether vaginal oestrogen or, in appropriate circumstances, testosterone should be considered
Whether persistent symptoms could have another cause
How your individual benefits and risks of HRT are changing over time.
And sometimes the conclusion is that nothing needs changing. Knowing that your treatment remains appropriate is valuable too.
What should I do if my HRT isn't working?
Don't increase the dose beyond what you've been prescribed, add different HRT products yourself or stop treatment without discussing it with an appropriate healthcare professional.
Instead, make a note of your symptoms. Think about what has improved since starting HRT, what hasn't, any side effects you've noticed and whether anything has recently changed. If you're still having periods, keeping track of your bleeding can also be useful.
Then book a review.
At Jaya Life, Dr Lucy Mather is a GP and British Menopause Society Registered Menopause Specialist. Appointments are designed to give you time to discuss the whole picture, not simply whether you should have more or less HRT.
If you started treatment with Jaya Life and are due your second or subsequent appointment, your follow-up is an important opportunity to make sure your treatment is still working as well as it can for you.
And if your HRT was prescribed elsewhere but you don't feel it is controlling your symptoms, you can book an appointment with Dr Lucy for a specialist review of your current treatment.
Because when HRT doesn't feel quite right, the answer isn't necessarily to put up with it, or to give up on it. Sometimes, it simply needs another look.