Three months. You've been on HRT patches for three months now and you're still waking up at 3am drenched, throwing off heat like a broken radiator while your partner's rolled to the far edge of the bed. Yesterday, in the Sainsbury's car park you forgot Sarah's name (you've worked with Sarah for four years) right in the middle of asking about her holiday. This morning you bit your husband's head off for chewing his toast too loud. Actually bit his head off. Over toast.
You take your patches exactly as prescribed. Change them on the right days. Haven't missed once. But you don't feel better. Actually, you feel worse. There are new symptoms now that weren't there before. Your mood's darker than it's been in months. You're so bloated your jeans won't zip up. And you're lying awake at 2am Googling "HRT not working" for the fifth time this week, terrified you're the one person it won't help, wondering if you've wasted three months.
We see you. Lying there in the dark making a mental list of everything else it could be, every terrible possibility. The not-knowing is doing your head in, isn't it?
Here's what you need to understand. HRT works for the vast majority of women. We've seen it time and again. When it seems like it isn't working, it's almost always because the dose needs adjusting, the type needs changing, or your body needs more time. Very rarely is it that HRT genuinely can't help you.
How long should HRT actually take to work?
Because if you've only been on HRT for a few weeks and you're panicking that nothing's changed yet, you might just need to hang in there.
Some women notice improvement within days. Hot flushes calm down, sleep gets better, that crushing fog lifts a bit. For others it's more gradual. A slow shift over weeks where you don't realize things are improving until you look back and think, hang on, I haven't had a hot flush in three days.
Most women see improvements within a few weeks, but it can take up to 3 months for HRT to work fully. That's why your menopause specialist will want to review you at the 3-month mark, not before.
Think of it like adjusting a thermostat in a house that's been freezing cold for months. You turn the heating on, but it takes time for the warmth to reach every room, for the walls to stop feeling icy, for the whole place to feel properly warm again. Your body's been running on fumes for months, maybe years. Low hormone levels have affected everything. Your brain chemistry. Your blood vessels. The tissues in your vagina and bladder. Your bones. The oestrogen you're taking now needs time to restore all of that.
Different symptoms improve at different speeds, which is frustrating when you want everything fixed immediately. Hot flushes and night sweats usually settle first. Mood symptoms and joint aches can take longer. Vaginal dryness and urinary symptoms? They can take several months because the physical changes to those tissues need time to reverse.
And here's the bit that's really unfair. It's actually quite common to feel worse before you feel better when you first start HRT. Your body's adjusting to having hormones back after months of declining levels. You might get breast tenderness, nausea, headaches, irregular bleeding in those first few weeks. These side effects usually settle within 4 to 6 weeks as your body adapts.
So if you're in weeks 2, 4, even 6 and still struggling, that doesn't necessarily mean it's not working.
The signs your HRT might not be working
But what if it's been 3 months or more and your symptoms haven't improved? Or what if things seemed better at first but now they're back?
Your original symptoms are still there
If the symptoms that made you start HRT haven't improved after 3 months, something needs changing. Persistent hot flushes, night sweats that soak the sheets, brain fog so thick you can't think straight, crushing fatigue, mood swings, joint pain, vaginal dryness.
The most common reason HRT doesn't seem to work is that the dose is too low for your individual needs. One woman might feel brilliant on one pump of oestrogen gel. Another needs three pumps to get the same relief. There's no standard dose that works for everyone, which is why this whole thing can feel like trial and error.
Symptoms that were better have returned
This one does your head in, doesn't it? You felt brilliant for months. Life was normal again. Then suddenly the hot flushes are back. The anxiety's crept in. You're waking up at night.
Your hormone levels are like a light on a dimmer switch that someone keeps turning down. As you move through menopause, your ovaries produce even less oestrogen. The dose that worked perfectly a year ago might not be enough now. The dimmer's been turned down another notch, and you need to turn up the brightness to see clearly again. Your hormone requirements can increase over time. This is completely normal and doesn't mean HRT has "stopped working."
You're getting symptoms that feel like PMS
Anxiety that wasn't there before. Low mood that feels heavier than your usual menopause mood. Bloating so bad you look six months pregnant. Breast tenderness. Headaches. Feeling weepy and irritable, particularly if these symptoms are worse during the days you take progestogen (and yes, we know you're now spiraling wondering if this means something else is wrong).
You might have progestogen intolerance. This affects around 10-20% of women taking combined HRT. Progestogen is what you need alongside oestrogen if you still have your womb to protect the womb lining. But some women are sensitive to it, especially synthetic types, and it causes symptoms very similar to premenstrual syndrome.
Think of it like this: oestrogen is trying to do its job, but for some women, certain types of progestogen create interferencelike static on a radio drowning out the music. The signal (oestrogen) is there, but the noise (progestogen side effects) makes it hard to hear.
We know you're probably wondering whether to just stop taking it. Don't. Because here's the confusing bit: these symptoms can make you think your HRT isn't working when actually it's the progestogen component causing problems, not lack of oestrogen.
You've developed new symptoms
Severe headaches that won't shift. Mood changes that feel darker than anything you experienced before HRT. Very heavy bleeding. Intense breast pain that keeps you awake. These are side effects rather than persistent menopausal symptoms, but they still mean your HRT needs reviewing.
You're exhausted all the time
Proper bone-tired. Dragging yourself through days despite getting enough sleep. This could mean your dose is too low and you're not getting enough oestrogen. Or (and this is going to sound odd) it could mean your dose is too high.
It's like overfilling a petrol tank—more isn't always better. When oestrogen levels get too elevated, some women develop symptoms rather than relief. Your body's saying 'too much' just as loudly as it says 'not enough.'
Why HRT sometimes doesn't work as expected
The not-knowing is often worse than the diagnosis, isn't it?
Your dose is too low
This is the most common reason by far. You'll typically start on a low dose to minimize side effects. Sensible. But that starting dose might not be enough to control your symptoms.
How much oestrogen you need depends on loads of things. Your age. How severe your symptoms are. How your body metabolizes hormones. Your body weight. Your genetics.
You're not absorbing it properly
If you're using patches, gels, or sprays, how you apply them matters more than you'd think. It's like trying to water a plant through a spray bottle with half the nozzle blocked. Are you putting gel on the same patch of skin every day? That reduces absorption. Rubbing it in like moisturizer? You're supposed to let it air-dry. Patches falling off in the shower?
Poor absorption is surprisingly common with transdermal HRT. You might be using the "right" dose on paper, but if your body isn't absorbing it properly, you won't feel better. Body lotions, fake tan, applying it to damp skin, putting it over hairy areas all affect absorption.
Got IBS or other gut problems? Tablet HRT might not absorb properly either.
Progestogen intolerance is making everything worse
If you still have your womb, you need progestogen alongside oestrogen to protect the womb lining. But progestogen can cause mood symptoms, anxiety, bloating, and other PMS-like effects in some women. Time and again, we see women struggle with this exact issue.
Synthetic progestogens are more likely to cause problems than body-identical progesterone. The Mirena coil releases progestogen directly into your womb, which causes fewer systemic side effects (the kind that affect your whole body) for most women, though some still react to it.
And yes, we know how unfair this is. You're just trying to manage menopause and now you have to deal with what feels like PMS on top of it.
If you had bad reactions to contraceptive pills, severe PMS, or postnatal depression, you're more likely to experience this.
Your symptoms aren't actually caused by menopause
This is the scary one to consider, isn't it? The one you've been Googling at 3am (we know you have).
Sometimes symptoms that seem like menopause are caused by something else. Thyroid problems. Vitamin B12 deficiency. Iron deficiency. Depression. Anxiety disorders. Sleep apnoea. Diabetes. They can all cause fatigue, brain fog, mood changes (symptoms that overlap with menopause). Blood tests can check thyroid function, vitamin levels, blood sugar.
It doesn't mean your menopause symptoms aren't real. It means there might be something else going on as well that needs addressing.
Lifestyle factors are working against you
HRT can't fix everything. If you're under severe stress, barely sleeping, drinking heavily, eating nothing but sugar and processed foods, or never moving your body, those factors will still cause symptoms even if your hormones are balanced.
When to speak to a menopause specialist
You've given HRT 3 months. Your symptoms haven't improved, or you're getting significant side effects, or you just feel like something isn't right.
Book an appointment with a menopause specialist. Your GP can refer you to a menopause specialist on the NHS, though waiting times vary by area.
Meet our clinical team at Voy Menopause.
Menopause specialists have specific training in hormone health that many GPs don't. They understand the nuances of different HRT types, different delivery methods, how to manage progestogen intolerance, when to check hormone levels, how to fine-tune treatment for individual needs. What we've learned from seeing thousands of women is this: those who see specialists get sorted faster.
Contact a menopause specialist if:
Your symptoms haven't improved after 3 months on HRT. You're experiencing severe side effects that don't settle within 6 weeks. You have heavy or irregular vaginal bleeding continuing beyond 6 months. Your symptoms returned after initially improving.
What will a menopause specialist do?
They'll take a detailed history of your symptoms, the HRT you've tried, how you've responded. They might check your hormone levels to see if you're absorbing your HRT and whether your levels are optimal. Blood tests aren't always necessary, but they can help if there's uncertainty about absorption or if you're on a high dose and still symptomatic.
They'll review whether you're using your HRT correctly, consider whether the type of progestogen might be causing problems, look at whether your dose needs adjusting. They might suggest switching from tablets to patches, trying body-identical progesterone instead of synthetic progestogen, or adding testosterone if low libido is an issue.
What happens next if your HRT isn't working
So you've seen a specialist. They've confirmed your HRT needs adjusting. What are the options?
Increasing your dose
Often, this is all you need. Your oestrogen dose can be increased gradually until your symptoms are controlled. Most HRT products have a range of licensed doses, and you'll try the next strength up.
With gel or spray, increase the number of pumps you apply. With patches, switch to a higher-strength patch. With tablets, try a higher-dose tablet.
Switching your delivery method
If absorption is the issue, changing how you take HRT can make a huge difference. It's like choosing between posting a letter that goes through multiple sorting offices (tablets through your digestive system) versus handing it directly to the person (patches or gel straight into your bloodstream). Sometimes the direct route just works better.
Switching from tablets to patches or gel means hormones go directly through your skin into your bloodstream, bypassing your digestive system. This often works better for women with gut issues.
Changing your type of progestogen
If you're struggling with progestogen side effects, several options exist. Switching from synthetic progestogen to body-identical progesterone (Utrogestan) helps many women. It's chemically identical to the progesterone your body makes naturally and tends to cause fewer mood and physical side effects.
The Mirena coil releases progestogen directly into your womb, so much less gets into your bloodstream. This reduces systemic side effects for many women.
Taking progestogen vaginally rather than orally can also reduce side effects. Utrogestan capsules can be inserted vaginally instead of swallowed.
Adding testosterone
If you're on HRT but still experiencing crushing fatigue, zero libido, poor concentration, low mood, you might benefit from adding testosterone. Women make testosterone too, and levels decline during menopause. Testosterone isn't licensed for treating menopause symptoms in the UK, but menopause specialists can prescribe it for women who aren't getting full relief from oestrogen and progesterone alone.
Trying a different approach
For the small number of women who genuinely can't take HRT or don't respond to it even when optimized, non-hormonal options exist. Certain antidepressants reduce hot flushes. CBT designed specifically for menopause helps with mood and sleep. Vaginal oestrogen treats vaginal dryness and urinary symptoms even if you can't take systemic HRT.
These aren't as effective as HRT for most women, but they do help.
You're not stuck with this
We know this whole process is exhausting. You just wanted HRT to work straightaway and make you feel like yourself again. Instead you're navigating doses and types and appointments and still feeling rubbish.
But here's what matters. The vast majority of women find an HRT regimen that works once it's properly adjusted. It might take a few tries to get the dose and type right. You might need to see a specialist rather than relying on your GP. You might need to advocate for yourself.
But you're not stuck feeling this way forever. HRT can be adjusted. Doses can be increased. Types can be changed. And with the right support from a menopause specialist, most women get to a place where symptoms are well controlled and they feel like themselves again.
You started HRT because you wanted your life back. You can get there.
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²- NHS. Continuous combined hormone replacement therapy (HRT) tablets, capsules and patches. https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/continuous-combined-hormone-replacement-therapy-hrt-tablets-capsules-and-patches/
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