For many women hormone therapy (hormone therapy) is the answer they have been searching for when it comes to minimizing, or stopping, their often soul-sapping perimenopausal or menopausal symptoms. Hormone therapy is generally agreed to be the gold-standard treatment because it addresses the very root cause of these symptoms – namely replacing declining hormone levels – the end result of which should help women to get back to feeling ‘like themselves’ again.
Unsurprisingly, many women are pretty evangelical about its benefits. Unfortunately, however, this is not true for everyone and there are some unlucky ones who find hormone therapy makes them feel worse than the very symptoms that caused them to seek it out in the first place.
What is Hormone Therapy?
Like any medicine, the hormones used in hormone therapy (estrogen, progesterone and in some cases testosterone[1] can potentially cause side effects.
It is also helpful to remember hormone therapy isn’t one standardized homogenous medication but comes in a range of strengths and modes of delivery (gels, pills, transdermal patches, pessaries, sprays and implants) and it can be a process of trial and error to get it right for you.
The type of hormone therapy you need will also depend on a range of factors including whether you have had a hysterectomy (in which case you will be prescribed estrogen-only hormone therapy) and the specific menopausal symptoms you are experiencing which will determine the most appropriate hormones and dosage. (Dr Shilpa McQuillan explains more in What is hormone therapy and who is it intended for?)
If you have recently been prescribed hormone therapy it can help to keep an open mind initially and not immediately write it off if it doesn’t seem to be agreeing with you from the outset. Most health professionals and manufacturers of hormone therapy suggest you allow around three months for your body to adjust to it. Often, any issues are temporary and/or fixable with a few minor adjustments but it helps to have accurate information about risks and potential side effects.
How to tell if hormone therapy is not working for you
What are the signs hormone therapy is not helping, why are some women more likely to encounter problems than others and what is the best course of action if it is making you feel worse than before?
The whole point of hormone therapy is to replace the hormones that your body no longer produces around the time of the menopause and, in turn, minimize, or put a stop to any debilitating symptoms triggered by them decreasing. If it doesn’t – or appears to be exacerbating them – this is indicating your Rx may need rethinking and/or tweaking. Symptoms to look out for can be both physical and/or psychological and may include:
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- Problems sleeping
- You are still having hot flashes and night sweats
- Unexplained weight gain
- Feeling sick
- Lack of libido
- Depression or low mood
- Bloating and fluid retention
- Fatigue/tiredness
- Irritability
- Muscle and joint pain
- Changes in your bowel habits
- Migraines and headaches
- Poor concentration and forgetfulness
- Feeling unusually angry
- Stress and worry
- Panic attacks
- Breast tenderness
- Acne and oily skin
- Hirsutism (excess hair growth)
- Dizziness
- High blood pressure
- Raised cholesterol levels
- Insulin resistance/pre-diabetes
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Some women are more prone to problems with hormone therapy than others
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- Hormone intolerance to progesterone – Typically, too, symptoms of an hormonal intolerance to hormone therapy (generally to progesterone) can be very similar to those of PMS or PMDD (Premenstrual Dysphoric Disorder, a particularly severe form of PMS) and if you have a history of suffering with PMS or PMDD symptoms in the past you may be at an increased risk of hyper-sensitivity to the progesterone in hormone therapy so it can help to be alert to any warning signs (including cramps, joint and muscle pain, insomnia, binge eating and food cravings, stress and worry).[2]
- Endometriosis – Research shows those who have had a history of endometriosis [1](a painful condition in which tissue similar to the lining of the uterus grows outside the uterus)[3] can find taking hormone therapy reactivates tissue growth and cause a recurrence of endometriosis.[4]
- Hypothyroidism – Also, women living with hypothyroidism (when the thyroid gland does not produce enough of the hormone thyroid) can experience issues with estrogen in hormone therapy which can interfere with thyroid medication and reduce the amount of available thyroid hormone in the blood. If you are being treated with thyroid hormone and start taking hormone therapy then you will probably need to increase your normal thyroid dosage to compensate for the effects of the estrogen and need to work out a carefully individualized plan with your physician.[5]
- Genital herpes – For women who have the genital herpes simplex virus there is also some evidence to suggest that progesterone in hormone therapy could increase susceptibility to infection.[6]
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Can you be intolerant to hormone therapy?
If you are struggling with more symptoms than before you started it, this can be a sign of a hypersensitivity. Dr Rebeccah Tomlinson M.D., a physician with a special interest in menopause explains what commonly causes it: ‘Most often, it is the progesterone component of hormonal treatments that women are sensitive to and this can lead to a lot of symptoms that could possibly be mistaken for other things like depression, PMT or irritable bowel syndrome (IBS).’ It is thought that around 20% of women taking hormone therapy can’t tolerate progesterone and around half of those affected will stop taking their hormone therapy because of the side effects it produces.[7]
Why is progesterone problematic?
Dr Tomlinson says, ‘Most of the progesterones that are prescribed to us throughout our lives as contraceptives or hormone therapy will be progestogens – synthetically created hormones that can be different in structure and compound make-up to the natural progesterones produced by your ovaries. The alternative to these are the newer “body identical” ones and micronized varieties which are being developed. These are more naturally sourced (currently from yam) and have more similarities to your body’s natural progesterone. Women tend to have fewer side effects with these and research has shown them to be safer in terms of risks of breast cancer, blood clot and heart disease. The most common body identical progesterone currently being used in HT is called Utrogestan.’
Estrogen tends to cause fewer problems but commonly can make you feel sick and headachy when you first start taking it. It can also trigger other gastrointestinal problems including abdominal cramps, vomiting, bloating, flatulence, diarrhea, and heartburn. Dry eyes and leg cramps are other recognized side effects.[8],[9] If you have been prescribed testosterone side effects are rare but can potentially include increasingly oily skin and acne, excess hair, and weight gain.[10]
What to do if your hormone therapy is making you feel ill
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- Track your symptoms using our tracker to pinpoint how they manifest themselves and if, and when, they get better or worse. Don’t automatically think you can’t tolerate any hormone treatments ever. As it is frequently pointed out just as there is no one size fits all solution for perimenopausal and menopausal symptoms, equally there is no one HT solution for every woman.
- Experiment. As Dr Tomlinson M.D. says, ‘Having side effects with one hormone therapy regimen should not stop you from trying an alternative type. Changing your hormone therapy to a formulation more tailored to your hormone sensitivities may reduce or stop some, or all, of the issues you are experiencing.’ It might be something as simple as changing to a different delivery method: side effects tend to be milder when using patches or pessaries than taking pills. When you take your hormone therapy is also significant – for example, if your tablet makes you feel nauseous many women say that taking it with food and at night can stop you feeling sick. It is also worth pointing out that some women have noticed when using patches or gels that the amount of hormone they absorb through their skin can vary according to the brand of hormone therapy they are using– so if yours appears to be too low or high it can be worth experimenting to find a brand that works best for you. In short, tweaking the dosage and altering the type of progesterone used and/or when you take your hormone therapy can all help. As Dr Tomlinson explains, ‘Progestogens and progesterones are either given sequentially (12-14 days in a 28 day cycle) or continuously (daily). Those on sequential hormone therapy may find a complete change in their symptoms on the days where they are taking both the estrogen and progesterone together, compared to the days when they just on the estrogen alone. If this is the case, then changing the progesterone being used or the timing of it would be advised.’
- Try a different form of progesterone. Micronized progesterone, made from yams, is also generally better tolerated, and metabolized than the synthetic versions – with the added benefit that it has been shown to help improve sleep quality, something that is often a key concern during menopause.[11] For this reason, it is generally recommended that you take yours at night.
- Work with an experienced and knowledgeable health professional. Dr Tomlinson is keen to point out that you need to discuss any changes with your physician. She adds that although as it might seem that taking less progesterone might ease any adverse side effects, reducing your dose could leave you with insufficient endometrial (lining of the womb) protection leaving you at an increased risk of endometrial hyperplasia and endometrial cancer. Speak to your physician if you are having issues so you get the maximum benefits from your hormone therapy.
Alternative treatments to hormone therapy
If ultimately you can’t find an hormone therapy treatment that you get on with or you simply don’t want to take it anymore there are other prescribed medicines that can potentially help including Selective Serotonin Reuptake Inhibitors (SSRIs) – antidepressants which are effective at reducing night sweats. Cognitive Behavioral Therapy (CBT) is a talking therapy that can help you deal with some of the more problematic psychological symptoms of menopause including stress, worry and mood swings. Vaginal lubricants are easily available online or at the pharmacist and can help reduce uncomfortable vaginal dryness.
There are also a range of diet and lifestyle changes that can help minimize perimenopause and menopause symptoms including taking regular exercise; eating a healthy menopause-friendly diet, taking vitamin and mineral supplements containing phytoestrogens (like yam), limiting alcohol, stopping smoking and finding effective ways to manage stress and worry. Many women find they can successfully manage their symptoms this way.
Sources & resources
[1] https://my.clevelandclinic.org/health/treatments/15245-hormone-therapy-for-menopause-symptoms
[2] https://www.psycom.net/premenstrual-dysphoric-disorder-pmdd/pmdd-or-pms
[3] https://www.hopkinsmedicine.org/health/conditions-and-diseases/endometriosis
[4] https://academic.oup.com/humupd/article/23/4/481/3814217
[5] https://pubmed.ncbi.nlm.nih.gov/30296186/
[6] https://journals.asm.org/doi/full/10.1128/JVI.77.8.4558-4565.2003#:~:text=Progesterone%20Increases%20Susceptibility%20and%20Decreases%20Immune%20Responses%20to%20Genital%20Herpes%20Infection,-Authors%3A%20Charu%20Kaushic
[7] https://academic.oup.com/humupd/article/3/2/159/840053
[8] https://patient.info/medicine/oestrogen-hrt-estradiol-conjugated-oestrogens
[9] https://www.sciencedirect.com/science/article/abs/pii/S0378512203003815
[10] https://thebms.org.uk/wp-content/uploads/2022/12/08-BMS-TfC-Testosterone-replacement-in-menopause-DEC2022-A.pdf
[11] https://pubmed.ncbi.nlm.nih.gov/29962247/
