The return of night sweats and 6 other signs it’s time to have your HRT reviewed, according to a women’s health GP

With more than two million women in the UK currently prescribed Hormone Replacement Therapy (HRT), navigating treatment is an ongoing journey rather than a one-off prescription. Hormone levels fluctuate continuously through perimenopause, meaning that a therapy that offered perfect relief a year ago might no longer meet a woman’s changing needs.

But while adjusting HRT is a routine part of care, many women suffer in silence when symptoms resurface or new issues arise. Be it a return of hot flushes and brain fog, struggling with subtle sleep disruptions, noticing unexpected bleeding, or dealing with local vaginal discomfort, changes in symptoms can signal that treatment should be adjusted. 

Dr Nikki Ramskill is a women’s health GP and founder of The Female Health Doctor. She says that recognising key signs – from lingering physical side effects to taking the same unreviewed dose for years – allows you to work with your doctor to tailor your dose, hormone type, or delivery method for optimal, lasting wellbeing. 

‘HRT isn’t something we prescribe once and then forget about,’ she says. ‘Finding the right HRT can be a bit like finding the right pair of jeans: what works brilliantly for one woman may be completely wrong for another, and what fitted you perfectly a year ago may not necessarily fit you now.

‘Hormone levels can continue to fluctuate through perimenopause, symptoms change, and our health and circumstances change too. Sometimes we also need to alter the dose, type of hormone or the way it is delivered.’

Seven signs that could mean it’s time to have your HRT reviewed

1. Your hot flushes and night sweats are creeping back

‘If HRT initially controlled your symptoms but you’re suddenly throwing the duvet off again at 3am, it sounds like you need a review.

‘During perimenopause, your own ovarian hormone production can fluctuate considerably, so a dose that was sufficient six months ago may no longer control your symptoms.

‘It is also worth checking how you’re taking your HRT. Patches can lift or fall off, while gels and sprays need to be applied correctly and consistently. Before automatically increasing the dose, I would look at the whole picture: your symptoms, adherence, application and whether anything else could be contributing.’

2. You’re sleeping badly again

Sleep is one of the symptoms Dr Ramskill says she specifically asks about when reviewing HRT.

‘Sometimes the problem is obvious: a woman is waking drenched in sweat. But menopause-related sleep problems can be subtler. Women may describe waking repeatedly, suddenly being wide awake at 4am or feeling exhausted despite spending enough time in bed.

‘If sleep initially improved on HRT and has deteriorated again, it is worth reviewing your treatment. But not every sleep problem is hormonal, so I would also consider things such as stress, alcohol, caffeine, sleep apnoea, restless legs and thyroid problems rather than simply escalating HRT.’

3. Your mood, anxiety or brain fog have returned

Women often expect HRT to help hot flushes, but some of the symptoms they find most disruptive are psychological and cognitive: irritability, anxiety, low mood, poor concentration and that frustrating feeling of walking into a room and forgetting why you’re there.

‘If these symptoms improved when you started HRT and are now returning, that’s worth discussing,’ she says

‘However, we shouldn’t automatically blame every change in mood on menopause. Depression, anxiety, ADHD, thyroid disease, iron deficiency, vitamin deficiencies, chronic stress and poor sleep can overlap significantly with menopausal symptoms. A good HRT review should ask, “What else could be going on?” rather than simply increasing oestrogen.’

4. Your breasts are constantly sore or you’re getting headaches

It is important to know that more isn’t always better with HRT, says our expert.

‘Breast tenderness, headaches, nausea and bloating can occur after starting or changing HRT and often settle as the body adjusts. But persistent symptoms deserve a review.

‘Sometimes changing the dose or delivery method can make a significant difference. A woman who doesn’t get on well with one preparation may feel completely different on another.

‘New breast lumps or other breast changes should be assessed rather than assumed to be caused by HRT.’

5. You’re bleeding when you weren’t expecting to

Some bleeding can be perfectly normal when starting or changing HRT, particularly during the first few months, but bleeding shouldn’t be ignored indefinitely.

‘If unexpected bleeding continues, becomes heavy or prolonged, or starts after you have previously been settled without bleeding, speak to your doctor. Depending on when it started, your HRT regimen and your individual risk factors, you may need your HRT adjusted or further investigation.

‘And if you’ve been through the menopause and aren’t taking HRT, any postmenopausal bleeding should always be checked.’

6. Sex has become uncomfortable despite taking HRT

It’s a topic not all women are comfortable discussing with their GP, but Dr Ramskill says a large proportion of menopausal women are affected.

‘Systemic HRT patches, gels, sprays or tablets can be working beautifully for hot flushes and sleep while vaginal and urinary symptoms continue,’ she says. ‘Women may notice vaginal dryness, burning, painful sex, recurrent urinary symptoms or suddenly needing to rush to the toilet.

‘This doesn’t necessarily mean your entire HRT regimen needs increasing. You may need local vaginal oestrogen alongside systemic HRT. It delivers a very small amount of oestrogen directly to the tissues that need it and can be used long-term where appropriate.

‘Women sometimes suffer with these symptoms for years because nobody specifically asks about them.’

7. You’ve been taking the same HRT for years without anyone reviewing it

Feeling well isn’t a reason to suddenly stop HRT, but Dr Ramskill says it could be a warning sign of an imbalance of hormones, and could mean a review is needed.

She says: ‘I look at much more than whether a woman is still having hot flushes. We discuss bleeding, breast health and screening, blood pressure, cardiovascular and bone-health risk factors, vaginal and urinary symptoms, sexual health and whether her current progesterone provides appropriate protection for the lining of the womb.

‘If you still have a uterus and use systemic oestrogen, adequate progesterone or another suitable progestogen is particularly important to protect the womb lining.

‘There isn’t a universal birthday at which every woman must stop HRT. The decision to continue should be individualised according to symptoms, health, risks and benefits. We don’t need as much oestrogen as we get older as well, so a review to bring down the dose can be helpful.’

Dr Ramskill says her hope is that more information enables women to understand that ‘HRT isn’t one drug at one dose’.

She says: ‘There are different hormones, doses, combinations and ways of delivering them. If something isn’t working, you don’t necessarily have to choose between suffering and stopping HRT altogether.

‘Sometimes you just need a review!’