What to do if HRT seems to have stopped working for you

Hormone replacement therapy (HRT) has transformed the lives of many women troubled by debilitating symptoms at menopause. But after taking HRT for a couple of years, some women find their symptoms begin to return. Why does this happen and what can be done to remedy the issue? We ask the experts.

While some women will breeze through menopause without so much as a hot flush, many more will experience a range of debilitating symptoms that can make life a misery.

Hormone replacement therapy (HRT) has been beset with issues over safety, side effects and misinformation, but the latest evidence suggests that in the majority of women who experience troublesome menopausal symptoms, the benefits outweigh the risks.

HRT has beneficial effects on the bones and possibly the heart in some women, and in 2015 The National Institute for Health and Care Excellence (NICE) published official guidelines recommending the therapy as an effective means of alleviating hot flushes, night sweats and low mood.

But although HRT can vastly improve quality of life for many women, it is not uncommon for menopausal symptoms to re-emerge after it has been used for several years.

Why menopausal symptoms may return

During perimenopause and early menopause the ovaries still produce a small amount of oestrogen and some will also be produced by fat throughout the body. It is the fluctuation and eventual decline of oestrogen at menopause that cause troublesome issues. HRT replaces the body's natural oestrogen, thus reducing symptoms.

A progestogen hormone is also given with oestrogen in combined HRT to protect the womb, so that the lining doesn't become too thick and cause endometrial cancer.

"The general recommendation is to start on a low-dose preparation and often that will be enough to top up the levels," says Dr Heather Currie, an associate specialist gynaecologist at Dumfries and Galloway NHS, and past Chair of the British Menopause Society.

A few years down the line the ovaries will produce less oestrogen and this may lead to a recurrence of symptoms.

"Some women may think their HRT isn't working anymore," she continues, "but it's doing what it's always been doing; it's just that the total amount of oestrogen in your system may be less. That’s quite a common reason for recurrence of menopausal symptoms and you may need to up your dose of HRT."

Dr Tina Peers, a menopause specialist at Chelsea and Westminster Hospital Menopause Clinic, agrees:

"A return of night sweats, flushes, not sleeping and so on is very indicative that your hormones are not quite in balance. I recommend all my patients have a blood test once a year as part of an annual review to see where their oestrogen is at and whether an HRT adjustment is required."

However, Currie points out that blood tests to measure hormone levels are not always considered necessary in managing HRT dosage and are not standard GP practice.

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Other contributing factors

As we age, other health issues may have similar symptoms to those of menopause; it is important to be aware of conditions such as type 2 diabetes and heart disease, and to consider whether the thyroid and liver are functioning normally.

Lifestyle issues, including weight gain, an unhealthy diet, alcohol and caffeine consumption, smoking and stress, can also trigger a return of menopausal symptoms.

"It's worth examining if any of these factors have changed and may be having an impact, rather than immediately increasing the dose of oestrogen," explains Currie. "I often see women who have increased their alcohol intake, have put on weight, or have other stresses going on and it's these lifestyle factors that are causing a return of symptoms. So increasing oestrogen may not address that."

How to give your HRT more oomph

As your ovaries produce less oestrogen over time, you may require a higher dose of HRT, but also a different delivery method.

"Transdermal skin patches are great for the oestrogen part, but there isn't a patch currently available that gives you the higher dose of oestrogen with balanced progestogen," says Currie.

"Sometimes women use an oestrogen-only patch and take progestogen tablets separately, or a Mirena coil intrauterine system can be used at this stage, which will put the progestogen directly into the womb."

Dr Peers is also an advocate of the Mirena coil:

"It is a very straightforward thing to have fitted and offers a low dose of progestogen that stops any inconvenient bleeding and sets up your uterus with a really thin lining, giving you five years of endometrial protection. You then have far more flexibility with the oestrogen dose."

Upping your oestrogen in patch form does not appear to increase the small risk of breast cancer associated with HRT use, but if you increase it orally there is a deep vein thrombosis risk that may be a concern, says Currie.

Peers is also inclined towards transdermal delivery (patches or gels) rather than tablets for the same reason.

"It's worth noting though that women vary in how they react to HRT and in absorption of hormones through the skin. I was using one brand of HRT gel and my levels dropped but when I switched to another brand it absorbed and levels went up, so it is worth experimenting and finding what works for you."

How long will I need to take HRT for to 'get through' menopause?

There's often confusion around the duration of the menopause - is it something you 'go through' and then have no further symptoms? And how long does it take to make the transition?

"When women say they're 'through' menopause they mean they've moved through the early fluctuating symptoms such as flushes, sweating, joint aches and mood changes," explains Currie. "This initial phase - caused by falling oestrogen levels - may last a short time, or a long time or be hardly noticeable, but the average duration is thought to be about seven years or so."

She is keen to point out that HRT does not delay menopause, but controls symptoms while they are present. In time some women come off HRT and don't experience a return of the early menopausal symptoms they had, or the symptoms are far less severe:

"This is because the effects of oestrogen deficiency change according to what stage we're at. Women may need their oestrogen dosage adjusted at certain points when on HRT, but just because they move to a higher dose that doesn't mean they will need to stay on a high dose ongoing. Oestrogen drops to a certain point and stays there; it doesn't keep dropping as we age."

Without HRT, there are some menopausal changes that will not resolve in time. Vaginal atrophy and associated bladder symptoms, and effects on bone density, are permanent.

"Vaginal atrophy and bladder issues caused by a lack of oestrogen will need ongoing management," says Peers. "Using pH-balanced lubricants, intra-vaginal probiotics and low-dose vaginal oestrogens (creams or pessaries) may help maintain vaginal health at menopause."

Your GP may be able to adjust your HRT dosage or refer you to a consultant for advice and management. Some hospitals offer specialist menopause clinics and the British Menopause Society can help you find a menopause specialist in your area. Menopause Matters is another great resource.

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