Dr Nirusha Kumaran, a functional medicine doctor and former GP, puts it bluntly: “one hormone does not fit all” for perimenopausal women. In perimenopause, the more common problem is mismatch: the wrong dose, the wrong delivery route, the wrong timing, or symptoms that are being driven by more than falling oestrogen alone.
Start with the right question
If standard HRT has not eased symptoms, the first move is not to abandon treatment. It is to review whether the current plan matches the body it is treating. Kumaran’s approach looks beyond the prescription itself to absorption, gut health, supplements, dosage, delivery form and broader lifestyle factors, because all of them can change how well treatment is felt.
Perimenopause is often messy. The NHS lists hot flushes, sleep problems, mood changes, brain fog, palpitations, headaches, joint pain and vaginal dryness among the common symptoms. NHS guidance puts the figure at around 80 to 90 per cent of women experiencing menopausal symptoms, and about 25 per cent describe them as severe and debilitating. In that context, partial relief is not unusual, and it does not mean the diagnosis or the treatment goal is wrong.
Why a standard prescription can miss the mark
HRT is the most effective treatment for menopausal symptoms, especially flushes and sweats, and the benefits usually outweigh the risks. NICE says HRT can be offered for hot flushes and night sweats after a discussion of risks and benefits. The issue here is not whether HRT has a role. It is whether the first version of it is the right one for the individual person in front of you.
Kumaran’s clinical view is that perimenopause care should ask why symptoms are happening now, what else is contributing to them, and which longer-term risks might be reduced by earlier intervention. She links midlife hormone optimisation with cardiovascular, muscle and cognitive health, which is a wider frame than hot flush control alone. NICE includes later health outcomes, including cardiovascular disease and dementia-related issues, in its rationale on HRT in early menopause.
Do not overread blood tests
There is a real debate about hormone testing in perimenopause, but the UK guidance is clear on one point: routine blood tests are usually not the answer. For people aged 45 and over with typical menopausal symptoms, NICE advises clinical diagnosis, and FSH testing does not help because hormone levels fluctuate during perimenopause and the result would not change management.
In its 2026 fact sheet, the British Menopause Society says hormone blood tests are generally not required to diagnose perimenopause or menopause, monitor HRT, manage symptoms, or address long-term health consequences in women in the average menopause age range of 45 to 55. It also says serum estradiol testing cannot distinguish between endogenous and exogenous estradiol in perimenopause. In practice, that means blood work may be useful in some specialist settings, but it should not be treated as the default solution when symptoms are still there.
For a GP conversation, the useful question is not “can I have a blood test?” first. It is “does my current regimen make sense for my symptoms, my stage of menopause and the way my body is responding?”
Match the delivery route to the symptom pattern
HRT comes in tablets, patches, gels, sprays, vaginal rings, pessaries and creams. The best option depends on factors including hysterectomy status, stage of menopause and personal preference. A woman who gets no benefit from one route may do better on another.
If symptoms are still breaking through, the next review should look at whether the body is absorbing the treatment properly, whether the dose is enough, and whether the route fits the symptom cluster. Kumaran’s point is that treatment can fail at several points before it reaches the hormone receptor, including absorption and wider lifestyle stressors.
What to track before the GP appointment
A useful consultation starts with specifics, not general frustration. Before a review, track:
- Which symptoms remain, and how often they happen
- Whether they are improving, unchanged or worse on treatment
- Sleep disruption, flushes, mood changes, brain fog, palpitations and vaginal symptoms separately
- Whether symptoms cluster around missed doses or changes in routine
- Any side effects, including bloating, breast tenderness or breakthrough bleeding if relevant
- Whether you have changed supplements, diet, alcohol intake, exercise or stress levels
What to ask for in the review
The consultation should focus on adjustment, not abandonment. Ask whether the current dose is low, whether the route should change from tablet to patch, gel or spray, and whether the timing of the dose is sensible for your symptom pattern. If symptoms are mainly vaginal, ask whether local treatment is needed alongside systemic HRT. If symptoms are still broad and disruptive, ask whether the regimen should be rebalanced rather than simply continued unchanged.
Kumaran also points to apparently simple interventions such as dry brushing. She argues that midlife care should be broad enough to look at the whole picture, including digestion, supplements, sleep and daily stress, rather than assuming a prescription has to carry the entire load on its own.
Know when to consider a different plan, not a stop
A treatment review is especially important if symptoms are affecting work, relationships or day-to-day function. NHS England says menopause symptoms can affect retention, productivity and absenteeism, and more than 260,000 women aged 45 to 54 work in the NHS workforce. The House of Commons Women and Equalities Committee received 2,161 responses to its menopause survey.
In women aged 45 and over with typical symptoms, NICE says diagnosis is usually clinical, not lab-based. The British Menopause Society says hormone blood tests are generally not needed for routine monitoring. The practical next step is a medication review with a GP or menopause clinician who can look at dose, delivery method, symptom mix and whether another route would suit better.