by Dr Rebecca Tomlinson, ⊕ medically reviewed by Dr Rebecca Tomlinson on 27th April, 2023
For many women HRT is the answer they have been searching for when it comes to minimising, or stopping, their often soul-sapping perimenopausal or menopausal symptoms. HRT 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 women who find HRT makes them feel worse than the very symptoms that caused them to seek it out in the first place.
What is HRT?
Like any medicine, the hormones used in HRT (oestrogen, progesterone and in some cases testosterone [1]) can potentially cause side effects.
It is also helpful to remember hormone therapy isn’t one standardised homogenous medication but one that 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 HRT you need will also depend on a range of factors including whether you have had a hysterectomy (in which case you will be prescribed oestrogen-only HRT) 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 HRT and who is it intended for?)
If you have recently been prescribed HRT 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 HRT 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.
Signs HRT is Not Working: How to tell if HRT is not working for you
So what are the signs hormone therapy is not helping? Why are some women more likely to encounter problems than others? What is the best course of action if it is making you feel worse than before?
The whole point of HRT is to replace the hormones that your body no longer produces around the time of the menopause and, in turn, minimise, or put a stop to any debilitating symptoms triggered by them decreasing. If it doesn’t – or appears to be exacerbating them – this is indicates your prescription may need rethinking and/or tweaking. Symptoms to look out for can be both physical and/or psychological. Some of the signs HRT is not working may include:
- Problems sleeping
- You are still having hot flushes 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
- Anxiety
- Panic attacks
- Breast tenderness
- Acne and oily skin
- Hirsutism (excess hair growth)
- Dizziness
- High blood pressure
- Raised cholesterol levels
- Insulin resistance/pre-diabetes
Some women are more prone to problems with HRT than others
- Hormone intolerance to progesterone – Typically, too, symptoms of an hormonal intolerance to HRT (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, or you have struggled to tolerate hormonal contraception in the past, you may be at an increased risk of hypersensitivy to the progesterone in HRT so it can help to be alert to any warning signs (including cramps, joint and muscle pain, insomnia, binge eating and food cravings. anxiety, depression and suicidal thoughts). [2]
- Endometriosis – Research shows those who have had a history of endometriosis (a painful condition in which tissue similar to the lining of the uterus grows outside the uterus)[3] can find the oestrogen part of HRT can sometimes reactivate tissue growth and restart symptoms related to endometriosis.[4]
- Hypothyroidism – Also, women living with hypothyroidism (when the thyroid gland does not produce enough of the hormone thyroid) can experience issues with oestrogen in HRT 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 HRT then you will need to work out a carefully individualised plan with your doctor or healthcare provider as your thyroxine dosage may need to be adjusted.[5]
- Genital herpes – For women who have the genital herpes simplex virus there is also some evidence to suggest that certain types of progesterone, most specifically the progesterone found in the Depo-Provera contraceptive injection could increase susceptibility to infection. Research on the progesterone elements contained within HRT have not shown such links.[6]
Can you be intolerant to HRT?
If you are struggling with more symptoms than before you started it, this can be a sign of a hypersensitivity. As Dr Rebeccah Tomlinson, a GP 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 per cent of women taking HRT can’t tolerate progesterone and around half of those affected will stop taking their HRT 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 HRT 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 micronised varieties which are being developed. These are more naturally sourced (currently from yam) and have more similarities to your body’s natural progesterones. 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 HRT is called Utrogestan.’
Oestrogen 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 recognised side effects.[8],[9] If you have been prescribed testosterone (although it is not actually licensed to treat menopause symptoms in the UK some specialists might prescribe it if they think you would benefit from it and it can be used to treat low libido) side effects are rare but can potentially include increasingly oily skin and acne, excess hair and weight gain.[10]
Here is how testosterone levels can be affected by menopause.
What to do if your HRT is making you feel ill
- 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 HRT solution for every woman.
- Experiment. As Dr Tomlinson says, ‘Having side effects with one HRT regimen should not stop you from trying an alternative type. Changing your HRT 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 HRT 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 the brand of HRT 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 HRT 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 HRT may find a complete change in their symptoms on the days where they are taking both the oestrogen and progesterone together, compared to the days when they just on the oestrogen 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. Micronised progesterone, made from yams, is also generally better tolerated and metabolised 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 GP or health provider. 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 GP if you are having issues to discuss it further so you get the maximum benefits from your HRT.
Alternative treatments to HRT
If ultimately you can’t find an HRT 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 Behavioural Therapy (CBT) is a talking therapy that can help you deal with some of the more problematic psychological symptoms of menopause including stress, anxiety and mood swings. Vaginal lubricants are easily available online or at the pharmacist can help reduce uncomfortable vaginal dryness.
There are also a range of diet and lifestyle changes that can help minimise 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 anxiety. Many women find they can successfully manage their symptoms this way.
Sources & resources
[1] https://www.nhs.uk/conditions/menopause/treatment/#:~:text=Testosterone is produced by the,the same time as HRT.
[2] https://www.psycom.net/premenstrual-dysphoric-disorder-pmdd/pmdd-or-pms
[3] https://www.nhs.uk/conditions/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 Increases Susceptibility and Decreases Immune Responses to Genital Herpes Infection,-Authors: Charu Kaushic
[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/
