What to expect when you start HRT: a Newson Clinic guide

You’ve had your first appointment with a Newson clinician and had your first hormone replacement therapy (HRT) prescription delivered – now what?

There are lots of different brands, types and doses of HRT, so starting HRT can feel a little daunting – even after you’ve had a discussion with one of our experienced clinicians about how and when to take your HRT prescription, and any initial side effects that may occur.

To help you get the most out of your treatment, here Newson Clinic looks at common questions many women have when starting out on HRT.

How long will it take for my symptoms to improve?

HRT is usually the first-line treatment to improve symptoms of perimenopause and menopause [1].

Every woman is different when it comes to symptom relief, and this can depend on the type and severity of symptoms you may be experiencing. As a general rule, symptoms like hot flushes and night sweats should subside within a few weeks of starting HRT, while other symptoms, such as low mood, muscle and joint pains and vaginal dryness can take longer to resolve.

What sort of side effects can happen when starting HRT?

Here are some common, temporary side effects that can happen in the first few weeks after starting HRT, known as the four Bs:

1. Bleeding

This could be brown discharge, light spotting or sometimes more like a heavy period and may come and go or last for a few weeks.

If you’re perimenopausal when you start HRT (and so are still having periods), bleeding patterns may alter initially and may take three to six months to settle into a regular pattern. If you’re menopausal when starting HRT (and are no longer having periods), bleeding may occur, but this usually settles within three to six months.

If bleeding is persistent and/or heavy or you have other symptoms with the bleeding, then you should contact Newson Clinic for a follow-up appointment: this could include an examination and/or further investigations.

It’s also important to point out that if you have any changes to the dose or type of HRT you use in future, bleeding can occur and take three to six months to settle when switching to a different dose or type.

2. Breasts

Your breasts may become tender, painful and more sensitive. This can last for several weeks but usually settles. Wearing a well-fitting, supportive bra can also help if you’re experiencing this symptom.

3. Bloating

If your HRT regimen includes progesterone or a synthetic progestogen, you may experience an uncomfortable, bloating feeling. Again, this should settle within time.

4. Blues

You may find that your mood is affected, or you feel more emotional than usual in the first few weeks after starting HRT.

Women often mistake these temporary side effects after starting HRT as a sign their treatment isn’t working. However, it’s important to remember to give your treatment time to take effect: every woman’s response is slightly different, but initial side effects should settle, often as symptoms start to improve.

Do I need to take my HRT at the same time every day?

It’s helpful to get into a routine so you remember to take/apply your HRT as directed. How this fits into your day is up to you: you may have more time in the evening to apply your gel, cream or patches, or you might find it works better when getting ready in the morning.

If micronised progesterone is part of your HRT regimen, you may find taking this in the evening works best, as it has a mild sedative effect – and ideally needs to be taken on an empty stomach.

I’ve missed a dose. What should I do?

It’s best to take/use your HRT at the same time each day, but the odd hour’s difference here or there is ok – what’s important is that you are taking the amount prescribed for you, as directed by your Newson Clinic clinician, on a regular basis.

If you have forgotten, or were unable to take your HRT one day, just continue with your normal dose on the next day. Doubling up on the dose may lead to side effects, such as headache or breast tenderness.

I don’t feel any different after starting HRT, or I’m feeling worse – what should I do?

Your Newson Clinic clinician may have given you a range within which to manage the dose yourself (for example, one to three pumps of oestrogen gel). You can alter the dose yourself if your clinician has recommended a range for you if you aren’t feeling the benefits of HRT – but just remember it can take a few weeks or months to respond to any changes you make.

If you don’t feel HRT has bought you the benefits you were hoping for after three months, you can discuss alternatives with your Newson Clinic clinician at your follow up appointment, including changing your HRT type or dose. Blood tests are often recommended to determine how well you are absorbing oestrogen and testosterone through your skin and to look at other causes of your symptoms, such as vitamin deficiencies or an underlying thyroid disorder.

It’s also helpful to continue tracking symptoms while taking HRT. You can download the free balance app to do this and create a health report to take to healthcare appointments such as follow ups.

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If you experience any side effects that are not mentioned here that are unexpected or persistent, or if you do not respond to treatment as anticipated, it’s important to consult your clinician promptly. Individual responses to treatment can vary, so always follow the advice of your clinician tailored to your specific health needs.

References

NICE (2024)  ‘Menopause: identification and management’