Hormone replacement therapy (HRT) is considered the most effective treatment for two of the most common symptoms of menopause: hot flashes and vaginal changes.(1) However, some women may feel that their prescription is not reducing symptoms as expected. There are a number of reasons why HRT may not initially produce the desired results. This article explores why HRT may not be working and how women can work with their doctor to increase the effectiveness of treatment.
Why It May Feel Like HRT Isn’t Working
HRT may be ineffective if the treatment regimen is not sufficiently tailored to a patient’s individual needs. HRT works by replenishing the estrogen and progesterone levels that decline during and after menopause. Both hormones support various aspects of reproductive health, including healthy uterine function, the menstrual cycle, puberty, fertility, and pregnancy.(2)(3)
Hormonal imbalances can cause bothersome perimenopause and menopause symptoms, including hot flashes and night sweats. HRT has been shown to effectively reduce weekly vasomotor symptoms in menopausal women by 75%.(1) However, there are many factors that can influence the effectiveness of HRT, particularly the dose and formulation. Certain doses and types of HRT may be effective for some women, but not as effective for others.
Common Reasons Why HRT Might Not Be Working
The following are potential reasons why HRT may not be effectively reducing menopausal symptoms:
Duration of HRT Use
It can take up to three months after starting HRT to experience a significant reduction in menopausal symptoms.(4)(5) For women who have just started treatment, more time may be needed to feel the full effects.
Ineffective Dosage
Depending on a woman’s age and menopause status, different doses of HRT may be needed to effectively relieve symptoms. Research has shown that women under 50 tend to respond favorably to higher doses of HRT, while low or medium doses may effectively relieve symptoms in women aged 50 to 59.(6) Most women enter perimenopause between the ages of 45 and 55.(7) If HRT isn’t working, it may be because the dose is too low for a patient’s needs.
Formulation Issues
Oral, transdermal, and localized HRT are all effective forms of treatment. However, some women may experience greater improvement with certain types of HRT, depending on their symptoms. Women experiencing symptoms of genitourinary syndrome of menopause (GSM), like vaginal dryness or painful sex, may benefit from localized vaginal estrogen therapy. While systemic treatments can also relieve vulvovaginal symptoms, localized HRT may be more effective because it’s applied directly to the vagina.(8) If HRT is ineffective, the formulation may not be the best fit.
Smoking
It’s recommended that women quit smoking if they are using HRT, as it may increase the risk of health issues. Smoking may also interfere with the effectiveness of oral HRT.(9) For this reason, transdermal HRT is recommended for women who smoke in order to maintain treatment benefits.
Starting New Medications or Supplements
Certain medications or supplements can interact with HRT, such as St. John’s wort. While research is limited, the supplement may help relieve menopausal symptoms. However, taking St. John’s wort while using HRT may reduce the effectiveness of treatment by altering the body’s hormone metabolism.(10)(11) It’s important to consult with a doctor before starting any new medications or supplements.
Key Signs Your HRT May Need to Be Adjusted
If any of the following menopausal symptoms do not improve or return after starting HRT, it may be a sign that the treatment regimen needs adjustment:
Hot flashes
Night sweats
Mood swings
Sleep disturbances
Vaginal symptoms
Low libido
HRT may also need to be adjusted if a patient experiences treatment side effects, such as the following:(8)
Nausea
Mood shifts
Breast tenderness
Headaches
Bloating
Fluid retention
What to Do If HRT Isn’t Working: Key Solutions
The following are steps that women can take to potentially increase the effectiveness of HRT:
Consulting with a Doctor
Women should talk with their doctor if their HRT prescription isn’t working for them. A healthcare provider can offer individualized solutions based on factors like the patient’s age, menopause status, medication use, and other relevant considerations.
Changing the Form of HRT
Depending on a patient’s symptoms or medication side effects, a doctor may recommend switching between systemic and localized HRT. They may also recommend changing the route of administration, which can include tablets, capsules, patches, or creams. Some patients may also respond more favorably to bioidentical hormones, which are chemically identical to the hormones produced in the female body.
Adjusting HRT Dose
Recommended starting doses vary depending on the form of HRT. A healthcare provider may increase the dose if a patient is not benefiting from treatment.
Making Lifestyle Modifications
Menopause is associated with cardiovascular risk factors, such as increased blood pressure and cholesterol levels. While HRT is not a preventive treatment for cardiovascular issues, it has been shown to benefit heart health. Maintaining healthy habits while using HRT may enhance these benefits. Results of one study found that engaging in aerobic exercise while using oral HRT yielded greater improvements in postmenopausal women’s systolic blood pressure (SBP) compared to exercise alone without HRT.(12)
Trying Alternatives
If a woman and their doctor decide that HRT is not a good fit, alternative treatments may be recommended. Evidence supporting the efficacy of these alternative practices is limited, but yoga, acupuncture, and weight-bearing exercises may help reduce menopausal symptoms. Certain vitamins, herbs, or supplements may also provide symptom relief.(13)(14) However, it’s critical that women speak with their doctor before discontinuing HRT or trying any new medications or supplements.
When Women May Need More Than Just a Dosage Change
An HRT dosage change may not always be the most effective treatment approach if other factors like underlying health conditions or medication changes are involved.
Underlying Health Conditions
If symptoms persist after adjustments have been made to the HRT dosage or route of administration, a doctor may recommend hormone testing to assess for any underlying endocrine disorders that could be affecting treatment.
Different Medications May Be More Appropriate
A doctor may recommend a different medication altogether if it may be more effective in treating specific symptoms. For example, there may be cases in which antidepressants may be more appropriate for a patient experiencing increased depression during menopause. There is also evidence suggesting that selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) may help alleviate hot flashes.(14)
Finding the Right Solution for HRT Needs
While some women may feel the effects of hormone replacement therapy within weeks, it may take longer for others to experience the benefits. Age, stage of menopause, and factors related to dosage or formulation can all influence treatment. For this reason, it’s important to stay in communication with a healthcare provider about what’s working and what isn’t. Adjusting the route of administration, changing the dose, or adopting healthy habits are potential solutions that may help increase the effectiveness of treatment. However, it may take a little experimentation before finding the right HRT regimen unique to each patient.
