What do you do when your HRT isn’t working? I see many women in my clinic who are struggling with their HRT

Often, they’ve come to me for a second opinion because their treatment isn’t working, and they’re feeling frustrated and let down. The truth is, HRT can be a game-changer when it’s tailored to the individual. But too often, it’s prescribed in a generic, one-size-fits-all way that doesn’t suit a woman’s specific lifestyle, preferences, or symptoms. Some women also find that the HRT that was once working well for them, is no longer working as well. Let me explain.

The Wrong Delivery Method

A big problem I encounter is women being prescribed HRT in a form that simply doesn’t work for their lifestyle.

  • Patches: Patches are great for many women, but not if you take a long daily bath or swim regularly—often they just won’t stick properly. If the patch isn’t adhered well, it can’t deliver the correct hormone dose, leaving you with persistent symptoms. Some women also develop skin sensitivity to the adhesive in the patches and if your skin is inflamed and sore, the hormone is absorbed less effectively.
  • Gels: Gels can be very effective, but they require time to dry—about five minutes. If you’re in a rush in the morning or evening, waiting for gel to absorb can feel impractical. In these cases, women may forget or skip applications, or simply don’t wait long enough before getting dressed and the gel rubs off on their clothes, this leads to inconsistent hormone levels and poorly controlled symptoms.
  • Sprays: Sprays can be quicker and more convenient than gels, but absorption can be variable. While some women find them a great fit, others struggle with inconsistent dosing.

Poor Absorption and Individual Suitability

Sometimes, the issue isn’t the method itself but how well your body absorbs the hormone. If patches, gels, or sprays aren’t working for you, oral HRT might be suitable, provided you don’t have contraindications such as a history of blood clots, high blood pressure, or smoking.

The Body-Identical HRT Trend

There’s been a lot of focus on body-identical hormones lately, especially body-identical (micronised) progesterone. Whilst body identical progesterone has been shown to come with a slightly lower risk of breast cancer compared to synthetic progestogens, the difference is very small.

The real problem arises when body-identical progesterone doesn’t adequately control symptoms like bleeding. Some women find themselves bleeding constantly on body-identical progesterone because it’s not strong enough. In these cases, either changing the dose of the body identical progesterone or switching to a synthetic progestogen—while less “natural”—is often the key to resolving the issue and allowing women to get on with their lives.

Cyclical vs. Continuous HRT: Clearing the Confusion

Another issue I see frequently is women being confused about cyclical and continuous HRT regimens:

  • With Evorel Sequi, for example, you use two weeks of oestrogen-only patches (Evorel 50), followed by two weeks of combined oestrogen and progesterone patches (Evorel Conti). If this isn’t explained clearly, it’s easy to mix up the patches and use them in the wrong order, leading to irregular or excessive bleeding.
  • Continuous HRT, designed to stop monthly bleeding altogether, can cause breakthrough bleeding if started too early in a woman’s menopause journey.

A large part of my consultation involves explaining these differences and ensuring women understand their regimen, so they get the best possible symptom control.

Dosage and Symptom Management

Sometimes, women are put on a standard dose of HRT, like a 50mcg patch, without anyone considering whether it’s sufficient for their symptoms. HRT doses can be adjusted safely within licensed limits. For example, if symptoms persist, patches can often be increased to 75 or 100mcg under supervision. Or if side effects develop like breast tenderness develops, the dose may need to be reduced.

The Role of Testosterone

One area that’s often overlooked is testosterone. Women with ongoing symptoms like low libido, testosterone can sometimes help. Some also women feel that they get additional benefits from testosterone such as improvement in energy and cognition, but more data is required to confirm this.

It’s not routinely offered, but for some women, it can be very valuble.

When HRT Isn’t the Whole Answer

While HRT is the most effective treatment for menopausal symptoms, it’s not a cure-all. Some women come to me feeling frustrated that HRT hasn’t fixed their anxiety, low mood, or poor sleep. In these cases, the issue might be something else:

  • Generalised anxiety disorder or depression: HRT won’t fix these conditions, which often require treatments like talking therapy, especially CBT, or antidepressants (e.g., SSRIs or SNRIs).
  • Underlying health conditions: Thyroid disorders, for example, can mimic menopause symptoms like fatigue, brain fog, and weight gain. If these aren’t addressed, HRT alone won’t help.

Lifestyle: A Crucial Piece of the Puzzle

Menopause management isn’t just about hormones and HRT. Lifestyle plays a huge role in how you feel:

  • Stress: Women in their 40s and 50s are often juggling work, family, and elderly parents while reaching the peak of their careers. Chronic stress can exacerbate symptoms like brain fog, fatigue, and anxiety. I talk to my patients about stress management techniques, including simple meditation and breathing exercises to rest their busy minds.
  • Exercise: Cardiovascular, restorative, and resistance training are all essential for bone health, cardiovascular health, joint pain and stiffness, and mood. I emphasise why movement matters and help women find practical ways to include it in their day.
  • Diet: I explain how diet impacts gut health, which in turn affects serotonin production and mood. Eating well—with an emphasis on whole, unprocessed foods—can make a significant difference.
    Many women also struggle with weight gain and comfort eating. I often talk about our innate association between food and comfort, stemming from infancy, and how recognising this can help break unhelpful habits.
  • Sunlight and Vitamin D: I remind women of the importance of getting outside daily, topping up vitamin D levels, and prioritising simple pleasures like fresh air.

Beyond ‘Medicalised’ Menopause

While menopause can cause real and disruptive symptoms, it’s also a natural stage of life, not a disease. In addition to medical options, I discuss holistic approaches such as acupuncture, cognitive behavioural therapy (CBT), and mindfulness. While the evidence base for some of these treatments is limited, they can still offer valuable support.

Cutting Through the Social Media Hype

Social media is full of celebrity endorsements claiming that HRT is the answer to everything. While HRT can be life-changing, it won’t resolve all the challenges of life. I often explain to women that HRT can improve menopausal symptoms, but it won’t fix stress, lifestyle habits, or burnout.

I also remind women to give HRT time to work. Improvements can take several weeks sometimes longer, and stopping HRT abruptly can cause symptoms to rebound. I always recommend making changes under the guidance of a doctor.

My Approach: Listening, Explaining, and Supporting

Women who come to me for help with their HRT often feel unheard and overwhelmed. My role is to listen to their concerns, drill down into their symptoms and lifestyle, and provide tailored solutions. Whether that means fine-tuning their HRT, addressing stress and burnout, or recommending additional therapies, I ensure they feel supported, understood, and empowered to navigate this stage of life.

Menopause is a journey, and no two journeys are the same. If you’re struggling with your HRT or feeling lost, know that with the right support, you can feel like yourself again.

Don’t suffer on – book an appointment today.