Menopause is something that all women have to go through, and it indicates the end of a female being able to conceive a baby naturally. Menopause often comes with a range of unwanted symptoms, but treatment can help to alleviate these. In this blog, we’re looking into the signs that HRT isn’t working.

What is HRT?

HRT stands for hormone replacement therapy, and it can be effective in treating some menopause symptoms. HRT is available in various forms. For example, it can come in tablets, patches or even gels. It’s important that you work with a clinician to find a suitable option for you.

Menopause begins as the levels of hormones in the female body start to decrease. There’s no real way of knowing when it will start, but it’s usually around the ages of 45 to 55. Some women may experience menopause sooner or later than this. HRT increases the levels of naturally occurring hormones such as oestrogen and progesterone.

Menopause symptoms

Everyone deals with menopause differently, so it’s important not to compare yourself to others. Some women may not experience many symptoms, while others may experience many. Some common menopause symptoms include the following:

• Changes to the period cycle
• Noticeable mood changes, such as low mood
• Difficulty with memory
• Hot flushes
• Trouble sleeping
• Headaches
• Body aches
• Skin changes
• Changes to your sex drive
• Weight gain

Many of these symptoms can have a significant impact on your daily life, so it’s important to seek advice if you are struggling.

Does HRT work for everyone?

We often speak to women who are worried about whether their HRT is working. Most of the time, this is due to them not being prescribed the right formulation rather than it not working. An example of this comes from oral HRT; for women who experience migraines, it can exacerbate them.

HRT isn’t suitable for everyone. A recent example being where it triggered histamine intolerance and caused significant eczema. However, when HRT is being used, there are usually things that can be done to optimise or tweak it for those who need it. Read our blog on menopause and allergies.

Before you start having HRT, you must ensure that you have discussed it in detail with a trained clinician. They can provide you with information to make an informed decision about your health.

Why is my HRT not working?

Hormone replacement therapy involves taking oestrogen to treat menopause symptoms alongside a synthetic progestogen or body-identical progesterone to prevent the thickening of the womb lining in response to oestrogen.

Progestogen and progesterone have a lesser role in symptom control that is not fully understood. The womb lining, or endometrium, cannot be allowed to thicken uncontrollably, or it can even become cancerous. HRT can be wonderful, but despite the current media rhetoric, HRT is not for everyone.

In my experience as a menopause specialist, when HRT doesn’t work, it is usually due to one of these four reasons.

Insufficient oestrogen dosing

This can be because too low a dose has been prescribed or the oestrogen is not being well absorbed via a patch or gel. Absorption is highly variable between individuals such that one woman will achieve a high level of oestrogen in their blood from a low dose 25 patch. In contrast, another woman may have low blood oestrogen levels despite the daily application of a maximum dose of Oestrogel (four pumps).

In these situations, it would be important to check the application technique. For example, in terms of Oestrogel, each pump should be applied to a different limb – upper outer arm or inner thigh and absorbed under the area of the handprint and not like moisturiser down the entire arm. Alternatively, you could try a different route of administration. The treatment aims to achieve blood levels of oestradiol of around 300-800 pmol/L.

Intolerance to progestogen or progesterone

A significant number of women do not get along with progestogen, and there may be clues in the history that this is going to be a problem, such as bad reactions to contraceptive pills in the past, premenstrual syndrome or dysphoric disorder and/or postnatal depression.

Side effects of progestogen can include mood disturbances, lethargy, and bloating. In these instances, it is important to minimise exposure to progestogen by using the lowest effective dose for the shortest time, as well as for some, maintaining steady levels throughout the cycle and avoiding fluctuations.

It can involve trialling several different types of progestogens to find the right one, including off-license use of medications that are not specifically tried and tested for this purpose but are anecdotally considered effective.

For most, it can be achieved via the use of a Mirena coil or vaginal use of body-identical progesterone, which limits absorption into the blood supply. A tablet called tibolone is another option for women below the age of 60 as this molecule has progestogenic properties without being a progestogen.

At the extreme, where women are unable to tolerate any progestogen but require oestrogen, women may consider a hysterectomy so that they no longer need to take it; however, this is clearly not without surgical risk.

Intolerable side effects from HRT

Clearly, progestogen intolerance sits in this category; however, other side effects of HRT can include nausea, headaches, heartburn, bloating, breast tenderness, leg cramps, and rashes. Here, it is important to balance the benefits against unpleasant side effects. Sometimes, there must be a tradeoff whereby some side effects can be tolerated and managed as best as possible for the overall benefit.

HRT may be ineffective

Despite achieving adequate levels of blood oestrogen (circa 300-800 pmol), sadly for some, HRT does not abolish their symptoms. For women who want to continue HRT, it is prudent to check oestradiol levels before reaching this conclusion. You cannot assume absorption simply due to using the maximum dose of a product, as some women do not absorb medication through the skin. If a symptom persists despite optimal oestrogen levels, then they may, in fact, not be caused by menopause or, sadly, not be responsive to HRT.

Menopause is a time to take stock and indulge in self-care, with or without HRT. Our menopause specialist is here to support you, so feel free to get in touch with any questions you have. We hope this blog has been useful on the signs that HRT is not working.