HRT remains the most effective treatment for menopausal symptoms, especially hot flushes and night sweats, but if it has not touched your flushes, sleep or brain fog, the problem is often the plan, not the treatment. Dr Nirusha Kumaran, a functional medicine doctor and GP, says “one hormone does not fit all” in perimenopause, and that the response depends on the whole body, not just the oestrogen prescription.
Its benefits usually outweigh the risks. But perimenopause is rarely neat: NHS guidance says most women will have symptoms, many will have more than one at once, and around a quarter describe them as severe and debilitating.
Why a standard prescription can fall short
A single dose of oestrogen will not suit every woman because the clinical picture changes with menopause stage, symptoms and how the body handles treatment. Dr Kumaran points to gut health, absorption, supplements, dosage, delivery form and broader lifestyle factors as reasons relief can be partial rather than complete. Her practical message is that HRT is one part of care, not the whole answer.
Perimenopause is not just about hot flushes. Common symptoms include sleep disturbance, mood changes, brain fog, palpitations, headaches, joint pain and vaginal dryness, and the menopause usually happens between ages 45 and 55, with the UK average age cited by Parliament as 51. If symptoms are still interfering with work, relationships or day-to-day function, that is not a reason to stop treatment; it is a reason to review it.
Check the form, not just the label
HRT comes in several forms: tablets, patches, gels, sprays, vaginal rings, pessaries and creams. The best option depends on factors such as whether you have had a hysterectomy, where you are in the menopause transition and what you prefer to use consistently.
That is where many women get stuck. If one route has not worked, it may be because the delivery method is wrong for the symptom pattern, or because the dose is too low for the level of symptoms. You may need to try different brands and methods before finding one that suits you, which is exactly why “HRT is not working” should trigger a review, not an exit.
Do not over-read blood tests
Blood tests are a live debate in perimenopause, but the official guidance is clear for most women in the usual age range. Otherwise healthy people aged 45 and over can usually be diagnosed from clinical history alone, NICE says, and routine FSH testing is not helpful because hormone levels fluctuate during perimenopause and the result would not change management. Hormone blood tests are generally not required to diagnose perimenopause or menopause, monitor HRT, manage symptoms or address long-term health consequences in women aged roughly 45 to 55, the British Menopause Society says.
In perimenopause, serum oestradiol cannot distinguish between the body’s own hormone and oestrogen taken as treatment, which limits its usefulness as a simple answer to “is the dose right?” That does not mean tests are never useful, but it does mean a test result should not be treated as a shortcut around a proper symptom review.
Track what is still happening
Before the next appointment, bring a clear symptom record. The point is not to produce a perfect diary, but to make the pattern visible enough for dose and route to be adjusted with purpose.
What to note
- Which symptoms are still present, such as flushes, poor sleep, mood changes, brain fog, palpitations, headaches, joint pain or vaginal dryness
- When they happen, and whether they are constant or cyclical
- Whether they worsened after starting HRT, improved briefly, or never changed
- Whether the problem is whole-body symptoms, or a specific issue such as vaginal dryness that may need a local treatment
- Any recent changes in supplements, diet, exercise, stress or sleep that could be affecting how you feel
This turns a vague complaint into a clinical review. It also helps separate a genuinely ineffective prescription from symptoms that need a different type of support.
Look beyond symptom control
Dr Kumaran frames midlife care as prevention as well as treatment. She links hormone optimisation in midlife to longer-term cardiovascular, muscle and cognitive health, and the broader debate in NICE’s rationale reflects that same question: whether HRT in early menopause may influence later health outcomes, including cardiovascular disease and dementia-related issues.
That wider lens also covers bone, cardiovascular and cognitive function. That does not mean HRT should be sold as a cure-all.
The House of Commons Women and Equalities Committee’s menopause survey drew 2,161 responses, and NHS England says menopause symptoms can affect retention, productivity and absenteeism among a workforce that includes more than 260,000 women aged 45 to 54.
Questions to take back to your GP or menopause specialist
Use this checklist
- Is my current dose high enough for the symptoms I am still having?
- Is this the best delivery method for me, or should we try a patch, gel, spray, tablet, ring, pessary or cream instead?
- Does my menopause stage mean I need a different approach now from the one I started with?
- If I have had a hysterectomy, or still have a uterus, is my overall regimen matched to that history?
- Could poor absorption or another body-wide factor be affecting how well this works?
- Should we stop focusing on blood tests and focus on a clinical review of symptoms and response?
- Do the symptoms that remain still fit perimenopause, or is there another explanation that needs checking?
If symptoms are still disrupting sleep, concentration, sex, work or daily life after a properly adjusted trial, see your GP or a menopause specialist.