What to Do When Menopause Symptoms Persist Despite HRT

This is precisely what proper assessment determines. Some indicators help guide us:

Likely hormonal symptoms that should improve with HRT:

• Hot flushes and night sweats
• Vaginal dryness
• Sleep disruption from night sweats
• Brain fog that’s episodic and worse at certain times
• Mood changes that fluctuate with your cycle (in perimenopause)

Symptoms that might indicate other factors:

• Extreme, unrelenting fatigue
• Severe depression or anxiety
• Breathlessness or chest discomfort
• Unexplained weight changes
• Digestive problems
• Severe headaches
• Hair loss or skin changes
• Cold intolerance

Mixed patterns:

• Persistent low mood (could be hormonal, thyroid, vitamin D, or depression)
• Ongoing fatigue (could be hormonal, thyroid, anaemia, sleep apnoea, or B12)
• Continuing brain fog (could be hormonal, thyroid, sleep quality, or stress)
• Joint pain (could be hormonal, autoimmune, or vitamin D)

The key is that if symptoms persist despite adequate HRT at optimal doses for 3-6 months, investigation is warranted.

No, don’t stop your HRT without medical guidance. Even if HRT hasn’t resolved all your symptoms, it’s still likely:

• Protecting your bones from osteoporosis
• Reducing your cardiovascular risk
• Preventing vaginal and urinary tract changes
• Providing some symptom relief, even if incomplete

What you need is additional investigation and treatment alongside your HRT, not stopping the HRT itself.

The exception is if you’re experiencing significant side effects. In that case, contact us to discuss adjusting your dose or changing preparation before stopping entirely.

The tests we recommend depend entirely on your specific symptoms. However, for persistent symptoms despite HRT, we typically consider blood tests for the following:

Essential screening:

• Thyroid function (TSH, free T4) – checks for under- or overactive thyroid
• Full blood count – identifies anaemia and other blood disorders
• Kidney and liver function – ensures organs are processing hormones properly

Very commonly helpful:

• Vitamin D – deficiency is extremely common in the UK and causes fatigue, low mood, and aches
• Vitamin B12 – deficiency causes fatigue, brain fog, and mood symptoms
• Iron studies – checks iron stores even if you’re not technically anaemic
• HbA1c – screens for diabetes and insulin resistance

Often valuable:

• Testosterone (total and free) – low testosterone causes persistent fatigue, low libido, reduced motivation
• Lipid profile – cardiovascular risk assessment
• Autoimmune markers – if symptoms suggest possible autoimmune condition

Sometimes needed:

• Coeliac antibodies – if digestive symptoms present
• Inflammatory markers – CRP, ESR for inflammatory conditions
• Cortisol – if severe stress or adrenal issues suspected

We don’t routinely check oestradiol levels in women on HRT as levels vary depending on when you test in relation to your patch or gel application, and symptoms are more informative than numbers. However, we might check FSH if we’re uncertain whether you’re menopausal.

Quite possibly. While testosterone is often discussed in relation to many aspects of wellbeing, the strongest clinical evidence for its use is specifically for low libido. By menopause, your testosterone levels are roughly half what they were in your 20s, and for some women, this change is noticeable.

While some women report improvements in their energy and mood, current clinical evidence supports the use of testosterone for libido benefits. Testosterone may be suggested by:

• Persistent fatigue and a lack of drive despite optimal oestrogen
• Very low libido that hasn’t improved with HRT
• Changes in physical strength or muscle tone
• Difficulty with motivation and confidence
• Persistent brain fog affecting work performance

If blood tests confirm low testosterone, we can discuss testosterone replacement therapy. Dr Summerhill can explain the evidence, monitoring requirements, and set realistic expectations.

You should consider reviewing your HRT if:

After 6 months on an optimised dose:

• Your symptoms haven’t improved at all
• You’re experiencing significant side effects
• New symptoms have developed since starting HRT
• You feel generally worse than before starting

However, this doesn’t necessarily mean stopping HRT. It means comprehensive assessment to understand why it’s not working as expected.

You might need:

• A different HRT preparation (patch to gel, different progesterone type)
• Additional treatments alongside HRT (testosterone, thyroid hormone)
• Investigation for underlying conditions
• Treatment for non-hormonal factors affecting your symptoms

Genuine HRT failure is rare. What’s more common is incomplete treatment or undiagnosed additional factors.

This can happen, particularly if:

• You’re under 45 (early menopause affects 1 in 100 women under 40, 1 in 10 before 45)
• Your periods haven’t stopped yet (perimenopause can last 10 years before the final period)
• Your FSH blood test was “normal” (FSH fluctuates wildly in perimenopause)
• Your symptoms are primarily mood, anxiety, or brain fog (very common in menopause)

At Summerhill Health, we use symptom-based diagnosis supported by appropriate investigations, rather than relying solely on blood tests that can be misleading. If you’ve been told your symptoms aren’t menopausal but they fit the pattern, at any age, it’s worth seeking a specialist opinion.

This pattern, i.e. symptoms returning or worsening at specific times, is very informative:

If using patches:

• Symptoms returning 36-48 hours after application suggest you need a higher-strength patch or to change it earlier
• Good control initially but symptoms returning by day 3-4 might indicate you need twice-weekly changes rather than weekly

If using gel:

• Symptoms worse in the evening suggest your morning dose isn’t lasting the full 24 hours
• Splitting your dose (morning and evening) might help
• You might need a higher total daily dose

If using tablets:

• Symptoms worse in evening, suggesting that once-daily dosing isn’t sufficient
• Splitting the dose might provide more stable levels

This timing information helps us adjust your dose more precisely.

We understand that persistent symptoms are exhausting and frustrating. Our same-day appointment availability means you can be seen quickly, often within 24-48 hours.

Your first appointment will involve comprehensive assessment and investigation planning. Blood tests can often be arranged the same day or within days. We’ll have results within a week and can arrange a follow-up consultation promptly to discuss findings and treatment.

Unlike NHS systems, where you might wait months between appointments, our flexible scheduling means we can review you every few weeks if needed to optimise treatment efficiently.

Normal blood test results don’t mean your symptoms aren’t real. They mean we need to consider:

Functional issues not captured by standard tests:

• Inadequate HRT dosing despite “normal” levels
• Sleep quality problems affect everything else
• Chronic stress maintains symptoms despite hormone replacement
• Medication effects
• Undiagnosed sleep apnoea

Psychological factors requiring specific treatment:

• Anxiety disorder needing CBT or medication
• Depression requiring treatment beyond HRT
• Trauma or PTSD

Less common conditions requiring specialist tests:

• Coeliac disease (simple blood test)
• Specific autoimmune conditions
• Chronic fatigue syndrome
• Fibromyalgia

We won’t dismiss your symptoms just because standard screening is normal. We’ll consider what else might be investigated or what treatments might help, regardless of test results.