Signs your HRT is not working, and what changes next

Signs the dose may be too low

• Hot flushes and night sweats continuing largely unchanged
• Still waking in the small hours
• Brain fog and low mood unimproved
• Symptoms that return reliably in the day or two before a patch change, which suggests levels are dropping before the next dose
• Some improvement that then plateaued well short of feeling like yourself

Starting doses are deliberately conservative. Needing more is expected, not exceptional.

Signs the dose may be too high

• Breast tenderness or swelling persisting beyond about three months
• Nausea, bloating or headaches that have not settled
• Leg cramps
• Feeling wired, irritable or unusually emotional rather than steadier

Signs the progesterone part needs changing

Progesterone is often the culprit when the oestrogen side is clearly working:

• Low mood, anxiety or irritability that tracks with the progesterone phase of a cyclical regime
• Bloating and breast tenderness in the same pattern
• Drowsiness disproportionate to the timing

The type, dose, route and timing of progesterone can all be changed while keeping oestrogen the same. Many women who believe HRT does not suit them have actually met a progestogen that does not suit them.

Signs it is not the dose at all

• Bleeding that is heavy, unexpected or persistent past six months on a continuous regime, which needs investigating rather than adjusting
• Symptoms that never fitted the menopausal pattern in the first place
• Fatigue as the dominant symptom with little else, where thyroid disease and anaemia are worth excluding
• Vaginal dryness and urinary symptoms unchanged, which often need local vaginal oestrogen in addition to systemic treatment rather than a higher systemic dose

What a clinician changes, in what order

1. Confirm you have had a fair trial, usually twelve weeks
2. Check absorption, including patch adhesion and where gel is applied
3. Adjust the oestrogen dose, usually upward in a single step
4. Change the route if absorption or side effects are the issue
5. Change the progestogen type, dose or timing
6. Add local vaginal oestrogen for genitourinary symptoms
7. Look elsewhere if the picture still does not fit

What about blood tests?

Routine monitoring of oestrogen levels is not usually needed when treatment is guided by symptoms. There are specific situations where levels help, including suspected absorption problems.

The main measure is how you feel, which is why recording symptoms properly matters more than most people think.

Why this should not cost you anything

A dose that is not right yet is a normal stage of treatment, not a new problem to be billed for. At fira, dose changes are reviewed by a clinician at no extra cost and your price does not move when your dose does.

If you are already on HRT elsewhere and it is not right, your assessment starts from where you are rather than from zero.