Hormone replacement therapy (HRT) is often life-changing for people going through perimenopause or menopause. By restoring hormone levels, HRT can ease hot flushes, low mood, anxiety, vaginal dryness, sleep problems, and more. However, not everyone feels better right away, and in some cases, things may feel worse before they improve.
If you’ve started HRT and feel more tired, emotional, or uncomfortable than before, you’re not alone. There are several reasons why this might happen, and in many cases, it’s temporary and manageable.
This guide breaks down why HRT might make you feel worse, how long it typically takes to settle, and when it’s time to consider adjusting your treatment plan.
Can HRT make you feel worse before it makes you feel better?
Yes, it can. As your body adjusts to changing hormone levels, it’s common to experience side effects, with 43% of women reporting them in one study [1]. These effects are usually short-lived and settle within a few weeks to three months [2].
Side effects of HRT can include:
- Unexpected vaginal bleeding or spotting
- Headaches
- Breast pain or tenderness
- Nausea
- Diarrhoea
- Mild rash or itching
- Hair loss
- Mood changes, including low mood, anxiety or depression
- Leg cramps
- Tiredness
- Dizziness
- Acne [2]
Reasons why HRT may not work as expected
Starting HRT and feeling worse can be disheartening, especially if you were hoping for relief. However, this doesn't always mean the treatment is wrong for you. Sometimes, it's about giving your body time to adjust or finding the right dose, type, or combination. There are several reasons why HRT might make you feel worse, especially in the first few months.
Fluctuating hormone levels
When you begin HRT, your body has to adjust to the reintroduction of hormones that may have been low or fluctuating for some time. This shift can temporarily unsettle the delicate balance between oestrogen, progesterone, and other systems like the thyroid and nervous system. The result can be symptoms such as fatigue, mood swings, bloating, or disrupted sleep.
Hormone sensitivities
Some people are more sensitive to particular types of hormones, with approximately 20% of women having significant progesterone intolerance [3]. This can result in adverse effects on:
- Fluid retention
- Skin
- Insulin resistance
- Mood [3]
If progesterone side effects are troublesome, adjusting the timing (for example, taking it at night), changing the dose, or switching to a different type or delivery method (like a hormonal coil) may help. Some people also tolerate cyclical dosing better than continuous, depending on their stage of menopause.
Dose-related issues
Both too much and too little hormones can cause side effects. If your oestrogen dose is too low, you may not get relief from symptoms like hot flushes, brain fog or joint pain. If it’s too high, it can cause overstimulation, leading to breast tenderness, anxiety, headaches or irritability.
The right dose is individual; there’s no one-size-fits-all. Some women are very sensitive and feel best on a low dose. Others may need higher levels to achieve optimal results. It often takes a few adjustments to get it right, and talking to your GP or a menopause specialist can help ensure you find the right prescription.
Incorrect type of HRT
The type of HRT you’re using can make a big difference in how you feel, as there are variations in the efficacy and effects of HRT pills, gels, spray and patches.
Oral oestrogen is processed through the digestive system and liver, which can sometimes cause side effects such as nausea. In contrast, transdermal options are absorbed through the skin and enter the bloodstream directly. This route may be better tolerated by some women and can be effective at lower doses.
Body-identical HRT, using transdermal oestrogen and micronised progesterone, is generally well tolerated and recommended by many menopause specialists. However, even within this category, adjustments may be needed depending on individual response.
Lifestyle factors
Your overall health and lifestyle can influence how well HRT works and contribute to menopause symptoms and their severity. This can result in you feeling worse or your symptoms not improving, even if you have started HRT.
- Smoking has been shown to reduce or completely cancel the effects of oral oestrogens [4].
- St John’s wort can impact the efficacy of HRT tablets and capsules [5].
- Obese women are more likely to experience stress incontinence and vasomotor symptoms [6].
- Alcohol can worsen menopause symptoms and increase the risk of numerous long-term health problems [7].
- Stress can affect the way medications, including HRT, are absorbed and metabolised by the body [8].
Underlying health conditions
Not all symptoms are caused by menopause, and not all can be solved by HRT. If you're feeling worse after starting HRT, it might be because other underlying causes remain untreated and are responsible for your symptoms.
- The symptoms of thyroid disorders can overlap with menopause symptoms [9].
- Being deficient in certain nutrients, such as vitamin B12 or iron, can result in extreme tiredness, brain fog and muscle weakness, even if oestrogen and progesterone levels are well managed [10,11].
- Mental health conditions, such as anxiety or depression, can also impact your physical well-being, resulting in fatigue, sleep disturbances, unexplained aches and pains and loss of libido [12]
Can HRT trigger anxiety symptoms
Anxiety is common among menopausal women, with 15 – 50% experiencing psychological and emotional symptoms [13].
There is a wealth of studies that report a beneficial impact of HRT on anxiety symptoms [14]. However, there is the potential for HRT to make anxiety worse. Although the risks of HRT are largely outweighed by the benefits, mood changes, including low mood, nervousness and depression, are known side effects of both oestrogen and progesterone [2].
Further, some research suggests HRT can worsen anxiety. In one study of 6000 peri and postmenopausal women, it was found that use of HRT in the previous month was associated with worse depression and anxiety, regardless of the type of oestrogen HRT used [15]. This may reflect underlying susceptibility rather than HRT itself causing anxiety in all users.
Can HRT worsen PMDD symptoms?
For those with a history of premenstrual dysphoric disorder (PMDD), hormone sensitivity and fluctuations play a key role [16]. As HRT introduces additional hormones into the system, it’s possible that HRT can make PMDD worse, at least temporarily, while your body adjusts.
However, as HRT eventually stabilises hormones, it may help to reduce PMDD symptoms in the long term. A Mirena coil alongside transdermal oestrogen offers balanced, targeted relief with fewer systemic progesterone side effects, making it an effective and well-tolerated combination for perimenopausal women with a PMDD diagnosis.
What you can do if HRT is not helping
If it seems like HRT is making you feel worse, it doesn’t mean that it won’t work for you; your prescription might just need adjusting. It’s also possible that other treatments used instead of or in addition to HRT might improve your well-being. Here are some changes your healthcare professional may suggest if you are not feeling better on HRT:
- Switch the delivery method: Many women tolerate transdermal patches, sprays or gels better than tablets.
- Adjust the dose: A smaller or split dose may reduce side effects while still easing symptoms.
- Change progesterone type: Micronised progesterone is usually better tolerated than synthetic versions.
- Add testosterone:If fatigue and low libido are present, testosterone may help restore balance. Note: While testosterone is not licensed for women in the UK, it can be prescribed off-label by specialists for postmenopausal women with low libido.
- Review lifestyle factors: Sleep, stress, alcohol, and nutrition can all affect how you feel.
- Combine with other treatments: Mood stabilisers, CBT, or non-hormonal medications may be helpful alongside or as an alternative to HRT.
Is it ever a sign that HRT isn’t the right choice?
If you're struggling with side effects, persistent symptoms, or just don't feel like yourself after 2–3 months on HRT, speak to your GP or a menopause specialist. You may need:
- A dose adjustment
- A change in hormone type or delivery method
- Tests to check for thyroid issues or nutrient deficiencies
- Support with lifestyle or mental health alongside HRT
Don’t assume HRT has failed, it often just needs fine-tuning.
¹Side‐effects of hormone replacement therapy and influence on pattern of use among women aged 45–64 years. The Norwegian Women and Cancer (NOWAC) study 1997 - Bakken - 2004 - Acta Obstetricia et Gynecologica Scandinavica - Wiley Online Library (August 2004)
²https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.0001-6349.2004.00560.x
³Side effects of hormone replacement therapy (HRT) - NHS (January 2023) https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/side-effects-of-hormone-replacement-therapy-hrt/
⁴Progestogen intolerance and compliance with hormone replacement therapy in menopausal women (1997) https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=4fd71629685cdd557862525f0445fc93f86406df
⁵Smoking, estradiol metabolism and hormone replacement therapy - PubMed (January 2005) https://pubmed.ncbi.nlm.nih.gov/15638743/
⁶Taking continuous combined HRT with other medicines and herbal supplements - NHS (January 2023) https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/continuous-combined-hormone-replacement-therapy-hrt-tablets-capsules-and-patches/taking-continuous-combined-hrt-with-other-medicines-and-herbal-supplements/
⁷Menopause care for obese and diabetic women - PMC (2009) https://pmc.ncbi.nlm.nih.gov/articles/PMC4251273/
⁸Health Issues in Postmenopausal Women Who Drink - PMC (2002) https://pmc.ncbi.nlm.nih.gov/articles/PMC6676683/
⁹Consequences of psychophysiological stress on cytochrome P450-catalyzed drug metabolism - ScienceDirect (September 2014) https://www.sciencedirect.com/science/article/abs/pii/S0149763414001286
¹⁰Thyroid & Menopause - British Thyroid Foundation https://www.btf-thyroid.org/thyroid-menopause
¹¹Vitamin B12 or folate deficiency anaemia - NHS (February 2023) https://www.nhs.uk/conditions/vitamin-b12-or-folate-deficiency-anaemia/
¹²Iron deficiency anaemia - NHS (January 2024) https://www.nhs.uk/conditions/iron-deficiency-anaemia/
¹³Symptoms - Depression in adults - NHS (July 2023) https://www.nhs.uk/mental-health/conditions/depression-in-adults/symptoms/
¹⁴Anxiety disorder in menopausal women and the intervention efficacy of mindfulness-based stress reduction - PMC (March 2023) https://pmc.ncbi.nlm.nih.gov/articles/PMC10086901/
¹⁵Strategies to cope with stress and anxiety during the menopausal transition - ScienceDirect (December 2022) https://www.sciencedirect.com/science/article/pii/S0378512222001670
¹⁶Effects of Hormone Therapy on Cognition and Mood - PMC (February 2015) https://pmc.ncbi.nlm.nih.gov/articles/PMC4330961/
¹⁷Using estrogen and progesterone to treat premenstrual dysphoric disorder, postnatal depression and menopausal depression - PMC (February 2025) https://pmc.ncbi.nlm.nih.gov/articles/PMC11882533/
¹⁸Non-hormonal-based treatments for menopausal symptoms - BMS (September 2024) https://thebms.org.uk/wp-content/uploads/2024/09/04-BMS-ConsensusStatement-Non-hormonal-based-treatments-SEPT2024-A.pdf
