HRT - Managing Expectations

If you are still having periods, it is useful (though not essential) to start taking the oestrogen part of your HRT within the first 5 days of starting your period. If you are also taking progesterone in a cyclical pattern (generally 2 weeks on, 2 weeks off), it is important to start your progesterone on day 15 of your cycle and take it for 14 days before stopping for 2 weeks (during which time you may have another period).

If you do not have periods anymore (and are going to be taking progesterone continuously), you can start your oestrogen and progesterone immediately or at any time to suit you.

Some women notice a difference within a few days, but for the majority it is a slow and steady improvement over weeks and months. You may notice physical symptoms get better first, for example, at the correct dose of oestrogen, hot flushes and night sweats are often much better after 4-6 weeks. However psychological symptoms, such as low mood or anxiety, can take a few more months to improve. It is important to take the HRT medication as explained for at least 3-6 months before deciding whether it is benefitting you or not.

If you have questions about how to apply your HRT, there is more information below on types of HRT. 

During the first few weeks after starting oestrogen and progesterone treatments, you may experience some:

  • breast tenderness;
  • vaginal bleeding or spotting; and/or
  • some abdominal bloating.


If taking progesterone, you may also notice a dip or change in your mood initially. If you notice certain side effects only during the two weeks you are taking progesterone, mention this to your menopause doctor at your 3-month follow up appointment.

Breast tenderness, bleeding, bloating and feeling low after starting HRT are not usually cause for clinical concern. If bleeding is heavy, persistent or prolonged, contains clots, or you are bleeding after sex, contact your clinician to discuss this further.

Less commonly, some women experience headaches, nausea or leg cramps as a side effect of HRT.

If using patches, sticky marks from the glue can be removed with baby oil and a cotton pad or dry flannel. If your skin becomes red from the patch, stick the next patch to a different area of skin. If skin irritation persists, mention this to your menopause doctor as there are often other brands to try that may not cause the same reaction.

If any side effects from your HRT have not settled down by your 3 month follow up appointment, you can discuss these further with your menopause doctor as there are often other doses, types or routes of administration that can be tried.

For most women, any side effects from HRT will resolve after 3-6 months.

It is common for your clinician to increase the dose of oestrogen after a few months to optimise symptom relief and achieve a ‘therapeutic’ level of estradiol in your blood. If your dose is increased, you may notice some side effects reappear, such as breast tenderness or bleeding, but again these should resolve after a few more weeks or months.

If you are taking oestrogen in gel or spray form, you may have been given a range of possible doses, for example 2-3 pumps of gel. If you have been using the lower number of pumps (or sprays) and symptoms are still troubling you, you can increase to the higher number within the range given to you at any time.

Some symptoms may not improve on the initial HRT regime provided for you. Or you may see good improvement of symptoms initially, and then feel as if some symptoms creep back in over time. This can be common and does not mean that HRT is not working for you. It often means your dose may need increasing slightly or you are not absorbing the medication as well for some reason. It may also mean that you might benefit from testosterone replacement as well as oestrogen (and progesterone).

Whatever the reason for ongoing or returning symptoms, there are usually other options to try so if you are not satisfied with your level of symptom relief, discuss this at your follow up appointment.

It is useful to make your HRT part of your daily routine if you are starting with oestrogen gel or spray. This means applying it at the same time every day, usually when getting up and dressed or when going to bed. You should avoid the application of moisturiser or sun cream to the area within one hour of application of your gel or spray.

If applying your gel or spray happens an hour or two later (on a weekend for example), it isn’t usually an issue. The important factor is taking the amount prescribed for you on a consistent basis.

If you are splitting your dose of gel or spray into a morning and evening application, 12 hours is an approximate guide of time between a split dose, but this is not essential. Don’t worry if you forget and it’s not exactly 12 hours in between; a few hours either side of this does not cause a problem.

If you are taking Utrogestan, it is usually advised to take it on an empty stomach before bed as it can act as a mild sedative.

The information contained in the box of most HRT medications is often inaccurate and is based on outdated research. Don’t let the leaflet cause you unnecessary worry.

For up to date and evidence-based information about risks of breast cancer or blood clot, read the HRT resource.