Hormone therapy for menopause replaces the oestrogen your ovaries stop producing. Hot flushes and night sweats are usually the first symptoms to ease, and NICE reviews the treatment at three months to decide whether the dose is right. This guide explains how long each symptom takes to respond, how the dose is adjusted, and what to ask at that review.
What hormone therapy for menopause actually does
Hormone therapy for menopause, usually called HRT, supplies oestrogen at a steady dose to replace what falling ovarian activity no longer provides. It treats symptoms. It does not restore the hormone levels of a 30-year-old.
If you still have a uterus, NICE NG23 says you should be offered combined therapy: oestrogen with a progestogen that protects the lining of the womb. If you have had a total hysterectomy, oestrogen alone is the recommendation.
The target is the lowest effective dose, in NICE's words. That means enough to control the symptoms that bother you, and no more. The starting prescription is a point on a scale, not a final answer.
How long does hormone therapy for menopause take to work?
Hot flushes and night sweats usually respond first. Relief arrives in stages rather than on a fixed date, and NICE judges the response at the three-month review rather than at a particular week.
Sleep often improves once the flushes that wake you at night settle. Mood, joint aches and energy follow more slowly, and part of that improvement comes from sleeping better rather than from oestrogen alone.
That is why the first formal review sits at three months: long enough to see whether the treatment works, and whether you tolerate it. Judging that means comparing how you feel now with the month or two before you started, not with how you felt at 35.
Vaginal dryness is the exception. Systemic hormone therapy, by tablet, patch, gel or spray, may not fix it. NICE recommends vaginal oestrogen for genitourinary symptoms, including for people who already use systemic therapy.
Starting low, and choosing the right regimen
The first prescription is a starting point. Because NICE recommends the lowest effective dose, the aim is the smallest dose that controls your symptoms, not the largest you can take.
If hot flushes persist at the three-month review, the dose can go up one step, or the route can change. If side effects are the problem, the dose can come down. Some people need two or three adjustments before they find a dose that suits them. That is expected, and it is what the review exists for.
Changes are usually made in steps, with a few weeks between them, so you can tell what each change did. A change of dose also restarts the clock on bleeding: NICE advises that vaginal bleeding is common in the first six months of treatment, and within three months of any change of dose or preparation.
In perimenopause the ovaries do not switch off cleanly. They produce oestrogen erratically, so symptoms arrive while cycles are still happening, and they can change from month to month. NICE recommends combined therapy for anyone who has a uterus, whether or not periods are still coming. While you still bleed, a sequential regimen, with oestrogen every day and a progestogen for part of each month, usually produces a planned bleed. Once periods have stopped, a continuous regimen, with progestogen every day, is the usual choice.
Contraception is a separate decision. NICE recommends sharing information about contraception with anyone who has menopause symptoms, because pregnancy is still possible while cycles continue. Hormone therapy is not a contraceptive.
What happens at the three-month review
NICE NG23 recommends that every treatment for menopause symptoms is reviewed at three months to assess efficacy and tolerability, and annually after that, unless something needs attention sooner.
The conversation covers three things: which symptoms have changed, which side effects you have, and whether anything new has appeared. NICE recommends referral to a healthcare professional with expertise in menopause if treatment has not improved your symptoms, or if side effects continue.
Breast tenderness, bloating, headaches and spotting are the common early side effects. Many settle as the body adjusts. If they do not, the dose or the route can be changed rather than stopping treatment altogether.
Bring three things to the appointment:
- A short log of symptoms, with a rough score from before treatment and one from now.
- Any bleeding: dates, how heavy, and whether it was expected.
- Your questions, written down, especially about how long you plan to continue.
Symptoms, timing and what to do next
| What you notice | What to expect | If it has not settled by the review |
|---|---|---|
| Hot flushes and night sweats | Usually the first symptom to respond | Ask whether the oestrogen dose or the route should change |
| Sleep and night waking | Often improves as flushes settle | NICE recommends menopause-specific CBT for sleep problems, alongside other options |
| Low mood without depression | May improve with hormone therapy | NICE says consider HRT for depressive symptoms that do not meet the criteria for depression |
| Vaginal dryness and soreness | Often needs a separate treatment | Ask for vaginal oestrogen, which NICE offers even alongside systemic therapy |
| Low sexual desire | Hormone therapy alone may not restore it | NICE says consider testosterone if HRT alone has not been effective |
Can a blood test tell you whether the dose is right?
Usually not. NICE advises against using laboratory tests, including oestradiol, anti-Mullerian hormone, inhibin A, inhibin B, antral follicle count and ovarian volume, to identify perimenopause or menopause in anyone aged 45 or over.
Hormone levels fluctuate from day to day, especially in perimenopause. A single sample can look normal on a day when symptoms are at their worst. The dose is judged on how you feel and which side effects appear, not on a number.
Blood tests do have a place. NICE says FSH can be used to confirm menopause in people aged 40 to 45 who have symptoms, and suspicion of menopause under 40 follows a separate pathway for premature ovarian insufficiency.
When the dose is fine but the route is wrong
Tablets, patches, gel and spray deliver the same oestrogen by different routes. Tablets pass through the liver first. Patches, gel and spray deliver oestrogen through the skin and skip that first pass.
NICE recommends considering transdermal oestrogen instead of tablets for anyone at increased risk of a venous blood clot, including people with a BMI over 30. For people at high risk, such as a strong family history of clots or an inherited clotting disorder, NICE recommends assessment by a haematologist before starting hormone therapy.
Route is also worth revisiting if patches irritate your skin, if a product is hard to obtain, or if your symptoms have not responded to a tablet at a dose that should work.
What hormone therapy does not fix
Hormone therapy is the most effective treatment for hot flushes and night sweats, and The Menopause Society notes that it prevents bone loss and fracture. It is not a treatment for everything the transition brings.
- Weight: hormone therapy is not a weight-loss treatment, and it does not reverse the shift in body fat that comes with the transition.
- Heart disease prevention: NICE says do not offer combined or oestrogen-only HRT for the primary or secondary prevention of cardiovascular disease.
- Dementia prevention: NICE says do not offer HRT in order to prevent dementia.
- Bone after stopping: fracture risk falls while you take HRT, but the benefit decreases once treatment stops.
- Unregulated preparations: NICE says the efficacy and safety of unregulated hormone preparations are unknown.
Does it matter when you start, and how long you continue?
The 2022 position statement of The Menopause Society found the benefit-risk balance most favourable for people under 60, or within 10 years of menopause, who have no contraindications. For those who start more than 10 years after menopause, or after 60, the balance looks less favourable, because the absolute risks of heart disease, stroke, blood clots and dementia are higher.
For people aged 45 or over, NICE states that taking combined or oestrogen-only HRT is unlikely to affect life expectancy overall.
NICE recommends discussing the possible duration of treatment at the start, and again at every review. There is no fixed limit. If you stop, symptoms may return, and NICE recommends explaining that in advance and discussing the option of restarting. It also recommends offering a choice between reducing gradually and stopping at once, so the decision is yours.
A worked example: the first three months
Suppose you are 51, your periods have become irregular, and you wake three or four times a night soaked. Your clinician starts a low-dose oestrogen patch with a progestogen, because you still have a uterus.
Weeks two to four: the night sweats are less frequent, but you still wake. You feel less irritable, probably because you are sleeping more.
Month two: the flushes are better but not gone. You mention it at the review, and the oestrogen dose goes up one step. Your breasts are tender for ten days, then settle.
Month three: you have a planned bleed, which is expected on sequential therapy. You also mention dryness during sex. Your clinician adds vaginal oestrogen, which acts locally and is separate from the patch.
Nothing in that sequence is unusual. The adjustments are the treatment, not a failure of it.
When to see a doctor:
- You have vaginal bleeding after the first six months of treatment, or more than three months after a change of dose or preparation.
- Your symptoms have not improved by the three-month review.
- Side effects are ongoing or troublesome enough that you are thinking of stopping.
- You find a new breast lump, or notice a change in the skin or the nipple.
- You have calf pain and swelling, or sudden breathlessness.
- You have a severe headache, or changes in your vision.