10 Signs HRT Might Not Be Working

Medically reviewed by

Date reviewed: 13/01/25

Menopause is a transition that all women will go through. As a result of menopause symptoms, such as night sweats, hot flushes, skin changes and joint stiffness, many women take the step of starting hormone replacement therapy (HRT) in a bid to alleviate discomfort and improve their overall well-being.

However, the effectiveness of HRT does vary between individuals, both in how long it takes to work and the symptoms that it addresses. Understanding how HRT works and what to expect can help manage expectations when you start treatment.

How long does HRT normally take to work?

This varies from one person to another. Some women may find that HRT starts working for them instantly. For others, changes can be more subtle and take a little time as the HRT restores hormones to an effective level and reverses the physical changes caused by months, or sometimes years, of depleted oestrogen and progesterone.

Can HRT make you feel worse?

It’s not uncommon to feel worse when you begin taking HRT before you start to notice improvements in your menopause symptoms. This is because it can take time for your body to adjust to the reintroduction of hormones which have been at lower levels in the body and every individual responds differently to hormonal changes.

In addition, determining the right type and dosage of HRT can be somewhat trial and error. You may find that your initial prescription needs tweaking to find the optimal balance.

Any side effects are usually the most pronounced within the first few weeks of starting treatment. They are normally short-lived, resolving themselves on their own as your body gets used to the medication, but some HRT side effects can be persistent.

It's also worth noting that HRT side effects and menopause symptoms can overlap. So, while you may have begun taking HRT to help with specific symptoms, you may develop additional symptoms and put their cause down to your HRT when this isn’t the case.

Signs that HRT might not be working

Every woman is unique and will respond differently to different HRT types and regimens, so an individualised approach is essential when determining whether HRT is working for you.

Ultimately, HRT is supposed to help reduce menopause symptoms. Therefore, a predominant indication that HRT is not working as intended is the prevalence of:

Night sweats
Hot flushes
Anxiety
Low mood and/or depression
Brain fog
Difficulty concentrating
Vaginal dryness, itching and/or discomfort
Decreased libido
Sleep disturbances
Headaches

Side effects of HRT

As with most medicines, HRT can cause side effects. However, not all women will experience side effects and those that do often only encounter mild ones. In some instances, it can be difficult to tell how well HRT is working at managing menopause symptoms as it generates similar undesirable side effects of its own. However, most side effects improve with time, so it’s recommended to carry on with HRT for at least three months to allow everything to stabilise.

There are many common physical side effects of HRT. You may experience none or just a few but could also be affected by many. Physical side effects may include headaches, nausea and sickness, breast tenderness, skin changes and changes to your period.

In addition to these side effects, some women also notice changes to their mood and emotions, especially in the first few weeks of starting HRT. Therefore, if you feel tearful, tired or a little blue, this isn't necessarily a sign that HRT isn't working, it's just that your body is acclimatising.

When it comes to HRT and weight gain, there is little evidence to suggest that taking HRT makes you put on weight. Instead, if you notice weight gain, it is more likely to be a natural result of age, slowing metabolism, and hormonal changes causing variation in where fat is stored in the body. Older women tend to store more fat around their abdomen.

Find out more about the side effects of HRT in our complete guide.

Why HRT can sometimes not work

While HRT is an effective treatment for menopause symptoms, it doesn’t work for everyone. Your medical history, health, lifestyle and a range of other factors can have an impact on how it works.

Incorrect HRT dosage

Hormone replacement therapy comes in various forms and strengths, and one size does not fit all. Women’s bodies respond differently to hormones like oestrogen and progesterone, and finding the optimal balance is key to relieving symptoms.

For instance, too little oestrogen may not alleviate symptoms like hot flushes, while too much can cause side effects like bloating or headaches. Some women may also need testosterone supplementation if their symptoms include fatigue or low libido.

Incorrect type of HRT

There are several ways to deliver HRT including pills, patches, gels, and sprays. Each of these methods has different absorption rates and effects on the body. Some women may not respond well to one form but find relief with another.

For example, oral oestrogen has to go through the digestive system and liver and can lead to side effects like nausea. Transdermal methods (patches, gels or spray) bypass the liver, delivering hormones directly into the bloodstream, which may be more effective for some women and can be effective at lower doses.

Hormone sensitivity

Women have varying sensitivities to hormones and their fluctuations. Some women may be more sensitive to small changes in hormone levels, making it harder to find the right balance with HRT.

Others don’t deal with progesterone very well and may have had adverse reactions to contraceptive pills in the past as a result. Side effects of progesterone can include fatigue, bloating and mood disturbances. If you experience such side effects, you may be advised to take the lowest effective dose for the shortest time possible or there may be careful adjustments that can be made by a specialist such as at Menopause Care which allows you to gain the benefits in spite of your sensitivity.

Underlying health conditions

Pre-existing health conditions such as thyroid disorders can affect how the body processes hormones.

For example, women with hypothyroidism may experience symptoms like fatigue and weight gain, which could be mistaken for menopause-related symptoms. If these underlying conditions are not addressed, HRT may not have the desired effect because the body’s entire endocrine system is out of balance.

Find out more about thyroid problems and menopause.

Bowel disorders can also affect how well oral HRT is absorbed into the body. In these instances, switching to a transdermal form of HRT which is absorbed through the skin, may be recommended.

Lifestyle factors

Lifestyle factors may influence the efficacy of HRT. Smoking, for instance, has been shown to reduce or completely cancel the effect of oral oestrogens.

Other factors, such as poor diet, alcohol and caffeine, and lack of exercise can exacerbate menopause symptoms, which could potentially mask the impact that HRT is having.

Medications and supplements

Taking HRT with certain medications and supplements can cause the medications or HRT to become less effective. For example, some HRT can interfere with epilepsy medication, making the condition less well-controlled.

Medications such as Modafinil, Rifampicin and Bosentan are predicted to decrease the effects of HRT as is the popular supplement, St John’s wort.

Misdiagnosis of symptoms

Not all symptoms commonly associated with menopause are necessarily caused by hormonal changes.

For instance, fatigue, mood swings, and depression could be related to mental health conditions, sleep disorders, or other medical issues. If these are misdiagnosed as menopause-related, HRT might be prescribed but won’t provide relief because the true underlying cause is not being treated.

What to do if you feel awful on HRT

If you’re struggling with the side effects of HRT, it may be tempting to stop taking it suddenly, but this isn’t usually recommended and can bring menopause symptoms back. Instead, it’s a good idea to speak to your GP or a menopause specialist as there are other options.

Try it out for longer

In most instances, it’s advised that you stick with your prescribed HRT treatment plan for at least three months. This is because symptoms usually improve over time as your body settles to new levels of hormones.

If side effects persist longer than 12 weeks or they are severe, then speak to your doctor about possible next steps.

Try a different type of HRT

Not all types of HRT suit everyone, and finding the right one often requires a period of adjustment. If you’re experiencing unpleasant side effects, speak to your doctor about alternatives. It may be that you can try a different hormone formulation, delivery method, or dosage. For example, some people find transdermal patches gentler on their system than oral tablets.

Consider other medications

If HRT alone isn’t enough or you’re struggling with specific symptoms or side effects, additional or alternative medicines for menopause symptoms might help.

For instance, antidepressants can be prescribed for mood swings or anxiety, while non-hormonal treatments like Veozah, oxybutynin, clonidine or gabapentin can address hot flushes. Herbal remedies for menopause can also be discussed. You might be recommended supplements or medications for bone health or heart protection if HRT isn’t right for you.

A holistic approach that combines HRT with other treatments could provide the relief you need.

Rule out other medical conditions

Feeling awful after starting HRT might not be entirely due to the hormone therapy itself. It’s essential to rule out other underlying health conditions that could be causing your symptoms.

Thyroid disorders, autoimmune diseases, or vitamin deficiencies can mimic or worsen menopause-related symptoms. If you’re concerned about other causes for how you’re feeling, it’s important to speak to your doctor.

Review your treatment plan

If you’re finding it difficult to manage the side effects of HRT or you don’t feel like it’s helping with your menopause symptoms, a thorough review of your HRT treatment plan with a healthcare professional is a good idea.

It’ll give you the chance to discuss how you’ve been feeling and ask questions. Dosage adjustments, switching to a new type of HRT, lifestyle changes or incorporating complementary therapies might be recommended. Your body’s needs can change over time, so a flexible, ongoing approach is key to achieving better results.

Why you shouldn’t stop HRT suddenly

HRT doesn’t always offer immediate relief, and it’s normal if you feel frustrated when you first start taking it if you don't experience a drastic improvement in your well-being. However, it’s important to remember that while HRT has a valuable place in managing symptoms, it isn't the remedy for all life's problems. Stabilising your hormones using HRT can leave you feeling better positioned to address the other issues that are contributing to your quality of life. Therefore, it’s vital to not discontinue HRT before it has even had time to fully work.

In addition, stopping HRT abruptly may cause unpleasant temporary withdrawal symptoms akin to menopause symptoms due to the drastic decrease in oestrogen.

If you want to stop taking HRT, it’s recommended that you come off it slowly in consultation with a doctor. Gradually decreasing your dosage can mean that menopausal symptoms return more slowly than when going cold turkey.

What to do next

If you feel HRT is not working after three months, it’s a good idea to talk to someone about your options, such as altering the type of HRT you are using, changing your dose or exploring holistic therapies, lifestyle changes and herbal remedies. Having blood tests can provide further insight into how your body is reacting to treatment and help inform the next steps.

At Menopause Care, we take a person-centred approach where we work with you to help you navigate this life stage, empowering you to make the right choice for yourself based on evidence and tailored advice. To get started, book a consultation with a menopause doctor.

DisclaimerAt Menopause Care, we ensure that everything you read in our blog is medically reviewed and approved. However, the information provided is not meant to replace professional medical advice, diagnosis, or treatment. It should not be relied upon for specific medical advice.

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