Already on HRT and It's Not Quite Right? What a Medication Review Looks At

So you've started HRT. The hot flushes are better, mostly. But your breasts are sore, you're bleeding at odd times, or you're still waking at 3am. Or maybe it worked brilliantly for a year and now the old symptoms are creeping back.

This is really common, and it doesn't mean HRT isn't for you. HRT isn't one fixed thing. There are different doses, different ways of taking it, and different types of progesterone. Getting it right often takes a tweak or two, and what suits you at 47 might not suit you at 53.

So here's what a medication review actually looks at, what's normal in the first few months, and which kind of bleeding needs checking straight away.

First, give it long enough

HRT takes time. It can take 6 to 8 weeks before symptoms settle properly, and around 8 to 12 weeks after any dose change before you know if the new dose is right. That's why the first proper review usually happens at about 3 months.

Some side effects are part of the settling in. Sore breasts are common in the first 6 to 8 weeks and usually ease. Spotting in the first few weeks or cycles is common too. So if you're 3 weeks in and something feels off, it may still settle. If you're 3 months in and it hasn't, it needs checking again, because the dose, route or type can usually be changed.

The free Symptom Tracker makes this much easier. Fill it in once a week, and note any bleeding. It turns "I think it's a bit better?" into something you can actually see.

Is it getting in properly?

Before deciding HRT isn't working, the first thing to check is whether it's actually getting into your body. This is the most overlooked part, and it's often the easiest to fix.

• Patches go on clean, dry skin below the waist, on your bottom or lower tummy. Move to a new spot each time. Don't put one on straight after a hot bath or shower, and check it isn't lifting at the edges. A patch that keeps peeling can give you headaches and symptoms that come and go.
• Gel goes on a large area of clean skin, where your pack says: usually the arms and shoulders, or the thighs. Smooth it on and let it dry, don't rub it in hard, and don't wash that area for an hour.

Some medicines also speed up how fast your body breaks down oestrogen, so less of it reaches where it's needed. More on that below.

The dose

If your symptoms have improved but not gone, the dose is often the first thing to change. Most women feel well on a middle dose, but some need more, especially younger women and women with early menopause. The aim is the dose that controls your symptoms safely, and for some women that's higher than the starting dose.

A blood test for oestradiol (the main type of oestrogen) isn't needed for everyone. Symptoms come first. But it helps when symptoms haven't settled on a higher dose, when we're not sure it's being absorbed, or when you're on medicines that affect it. Then the number tells us whether to change the dose or the route.

And if your breasts are sore and staying sore, the dose may be a bit too high. Going down a step usually helps.

The route: through the skin or a tablet

Oestrogen through the skin (patch or gel) is usually the first choice in the UK. It doesn't seem to carry the small extra risk of blood clots that tablets do, and it doesn't affect blood pressure or blood fats in the way tablets can. If you're on tablets and have a higher clot risk, high blood pressure or migraines, ask about switching.

Between the skin options, it's mostly about what suits your life. Patches are simple, but some women get itchy, red skin under them, or they come off in the bath or the gym. Gel doesn't cause that, and gel makes it easy to change the dose in small steps. If one route isn't working for you, another often does.

If you'd like a clear starting point for your review, these help.

Progesterone: the type and the timing

If you still have your womb, you need progesterone (or a similar hormone) alongside oestrogen. It protects the womb lining, which would otherwise thicken on oestrogen alone. If you've had a hysterectomy, you usually don't need it.

There are 2 main ways to take it:

• Cyclical, for 12 to 14 days a month, if you're still having periods or your last period was less than a year ago. You'll usually get a bleed a few days after each course ends. Fewer than 10 days a month isn't enough to protect the lining.
• Every day, if it's been 12 months or more since your last natural period. The aim is no bleeding at all once things have settled.

Body-identical progesterone, the same as the one your body used to make, is taken at night and can make you sleepy, which a lot of women find helpful. But some feel low, bloated or foggy on it. If that's you, there are options: a different way of taking it, a different type of progestogen, or a hormonal coil, which puts it straight where it's needed. You don't have to just live with it. I've written more about what progesterone does and why it has a bad reputation here.

Bleeding: what's expected and what needs checking

On cyclical HRT, a bleed a few days after each progesterone course is expected. If it becomes very heavy, lasts much longer, or the pattern changes, it needs checking. Sometimes the course is too short or the dose needs adjusting. Sometimes it needs a scan.

On every-day HRT, irregular spotting in the first 3 to 6 months is common while the lining settles. If spotting is still happening after 6 months, that needs checking too, usually with a scan. After 6 months with no bleeding, any new bleeding needs checking. Don't assume it's the HRT.

If you're not on HRT, any bleeding after 12 months or more without a period needs an urgent GP appointment, and you can ask for an urgent suspected cancer referral by name. Often it turns out to be something simple, but it has to be checked quickly.

Testosterone, interactions and timing your reviews

Testosterone. If low sex drive is bothering you, testosterone may be considered. The usual national approach only considers testosterone once oestrogen has been tried for a while. In clinic, low desire is asked about from the first appointment and decided with you, on your symptoms and blood tests. It isn't a general energy boost. It's a prescribing decision, it's checked with blood tests, and the aim is a normal female level, not more. Here's what testosterone can and can't do for women.

Interactions. Some epilepsy medicines, some antibiotics used for TB and St John's wort can speed up how fast oestrogen is broken down. If you take thyroid medicine, oestrogen tablets can change how much you need, so your thyroid level may need checking after you start or switch. Blood thinners, other hormones and herbal products all need mentioning too. Bring a list, or the boxes.

When to review. About 3 months after starting or after any change, then at least once a year. Each review should include your blood pressure, how your symptoms are, your bleeding, any side effects, new medicines, family history, and whether you're up to date with breast and cervical screening.

If you'd like help with it

A medication review is part of the clinic's Menopause service, which starts on Sunday 18 October, World Menopause Day. It's for women already on treatment as well as women just starting, online, by video or voice call, anywhere in the UK. We go through what you're on, how you're using it, your symptoms, your bleeding pattern and your family history, and arrange blood tests where they'll change the plan. There are around 40 clinics across the UK for the blood draw, so most women can have it done near home. Then we talk through the options together. If a prescription change is the right option for you, it goes through the doctor and pharmacy we work with, and I write to your GP where it's needed.

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Debora Tentis, Women's Health Pharmacist.