What to Expect After Starting HRT?
Article written by Dr Mari Walling, British Menopause Society Registered Specialist, GP, Co-founder of Lemala Health, January 2026
This information is not a substitute for professional medical advice, diagnosis, or treatment. Always consult your healthcare provider for personal guidance.
This is a guide for women on the most frequently asked questions after your initial appointment or after starting Hormone Replacement Therapy (HRT).
1. When will I start to feel better on HRT?
The improvement in symptoms, that women feel with HRT is gradual, not instant. HRT provides oestrogen and where needed, progesterone, and it can take time for your body to adjust and respond.
Some symptoms tend to respond earlier than others.
Symptoms which often improve within 2 to 4 weeks:
Hot flushes and night sweats
Slight improvement in sleep continuity
Symptoms which often take longer:
Anxiety and low mood
Brain fog and concentration
Energy levels and motivation
Confidence and emotional resilience
Many women describe early improvement as “things feeling less intense” rather than suddenly feeling like themselves again.
Is it normal to feel worse at first?
This can sometimes be the case. It's important to be aware of this, as this can be unsettling.
We would often refer to these initial side effects, the 4 B's.
In the first few weeks you may notice:
Breast tenderness
Bloating
Blues: Feeling emotionally a bit up and down
Bleeding
This does not usually mean the treatment is wrong. It is often your body noticing that your hormones have changed.
In most women, side effects are mild and settle quickly. Please be reassured, a little time is often all that is needed.
Of course, if you are really struggling please do get in contact with us, we are here to support you.
How long before we know if HRT is working?
A review is usually done at 8 to 12 weeks. This allows time for:
Your body to respond to the treatment
Changes in symptoms to become clearer
Early side effects to settle
If there has been little or no improvement by this stage, or if side effects are ongoing, this usually means something needs adjusting rather than stopping treatment altogether.
2. Bleeding or spotting after starting HRT
Any bleeding changes after starting HRT can feel concerning. Please don't worry, this can be completely normal.
Some bleeding outside what we would normally expect for your type of HRT is called 'unscheduled bleeding'.
Different HRT preparations have different patterns:
If you are perimenopausal and still having natural periods (ie. not due to contraception), you can usually expect a regular, predictable monthly bleed while on HRT.
If your periods have already stopped, you will likely be started on continuous HRT, which is designed to be bleed-free.
What you might notice if you are perimenopausal:
If you are still having periods, starting HRT can change your bleeding:
Periods are often lighter than before
Bleeding may be shorter or less regular
Some spotting between periods is common
What you might notice if you are menopausal:
There can be a “settling in” phase of up to six months, where some spotting or irregular bleeding is common. This is usually temporary and not a sign of anything serious.
This is common in the first 6 months after starting or changing HRT and often settles on its own.
These changes are usually due to the progesterone in your HRT, which helps protect the womb lining but can alter your usual cycle. In most cases, this is normal and not a cause for concern.
When to contact us
Please get in touch if:
Bleeding feels heavy or lasts longer than expected
It continues six months after you have started HRT
Bleeding starts after you’ve been settled on the same dose and type of HRT for a while
You are worried or unsure
You don’t need to wait to see if it gets worse. We are here to support you.
Does bleeding mean HRT is unsafe?
Most of the time, no. Unscheduled bleeding usually means the HRT regimen can be reviewed or adjusted, rather than stopped. Serious causes are rare, but it is always worth checking.
If you have additional risk factors - such as a family history of womb problems, obesity, or diabetes - we may recommend extra monitoring, but the majority of women will only need a simple review.
What happens next ?
When you contact us, we will:
Offer support via email or a phone call, if clinically safe.
Sometimes suggest bringing your next appointment forward.
Talk through what is happening
Check whether any changes to your HRT are needed
Decide if further investigations are required
Bleeding is one of the most common reasons women lose confidence in their HRT. It is usually temporary and manageable. If something doesn’t feel right, let us know.
3. Why does progesterone make me feel worse?
Progesterone, also called a progestogen, is an important part of HRT for women who still have a uterus. It protects the womb lining. Some women notice side effects when taking it.
Common experiences:
Some women feel a little “premenstrual” while taking progesterone. This can include:
Bloating
Headaches
Feeling more irritable or low in mood
Feeling sleepy or foggy, especially in the morning
These effects are usually mild and often settle within a few weeks. For a small number of women they may last longer.
Different types of progesterone
Micronised progesterone (ie. utrogestan, gepetrix):
This can initially make you feel low in mood or a bit foggy in the mornings. Most women find these effects improve within the first three months or three cycles if taken sequentially. Taking it earlier in the evening can sometimes reduce morning grogginess.
Timing and food:
Micronised progesterone is usually taken once a day at bedtime. Taking it at night helps manage drowsiness and lets the hormone work naturally while you sleep. It is best taken on an empty stomach, at least two hours after eating or an hour before a meal.
Food increases how much progesterone your body absorbs, which can make side effects such as sleepiness, dizziness or mood changes more noticeable. Adjusting when you take it can often make these effects easier to manage.
Norethisterone (found in Evorel Conti, Sequi or Conti patches), or other synthetic progestogens:
Some women notice more “premenstrual” side effects with this type. Switching to micronised progesterone may be better tolerated alongside oestrogen.
What to do if side effects are bothersome
Do not just push through. Let us know. Adjusting the type, dose or timing of progesterone can make a big difference.
Mood changes, bloating or fogginess usually improve over time, but persistent side effects are important to discuss.
Small adjustments or switching to a different progestogen can help you feel more comfortable while continuing HRT safely.
4. Starting local oestrogen, what to expect:
Local oestrogen, delivered as a cream, pessary or ring, is often used to improve vaginal and/ or vulval dryness, discomfort, or urinary symptoms. Most women tolerate it very well, but some notice minor effects when they first start.
Common experiences:
Mild stinging or irritation at the application site
Spotting for a few days after starting
Occasionally, a yeast infection (thrush) can be triggered
These effects are usually temporary and often settle once your tissues get used to the oestrogen.
General advice:
Start gently: for the first few weeks, consider reducing the frequency of use to allow your body to adjust
Use the smallest effective amount each time
Continue or start local vulval or vaginal moisturisers to help ease dryness and irritation
Avoid soaps, perfumed products, or douching in the area.
If thrush develops, see a pharmacist or GP for treatment, then restart local oestrogen. Long-term use of local oestrogen actually helps prevent future thrush episodes by keeping tissues healthy.
When to contact us
Contact the clinic if:
Irritation continues or worsens
Spotting continues for more than a few weeks
Local oestrogen is highly effective and safe, and minor irritation usually does not mean you need to stop treatment. Adjusting the dose, type, or frequency can make it more comfortable if needed.
5. What to do if you miss a dose of HRT ?
Missing an occasional dose of HRT is very common and rarely causes harm. In most cases, you can simply continue as normal without needing medical advice.
Do not double up on your dose the next day. Taking extra HRT can cause more side effects than the missed dose itself, such as headaches, breast tenderness, or nausea.
If unsure or multiple doses are missed, check with your menopause specialist or pharmacist.
If you are regularly missing doses then speak to your healthcare professional about how to make your medicines fit more easily into your daily routine.
Oestrogen
Tablets
Take the missed tablet as soon as you remember.
If it is nearly time for your next dose, skip the missed one and continue as normal.
Patches
Apply a new patch as soon as you remember.
Change the next patch on your usual day.
Gels or sprays
Apply the missed dose when you remember.
Resume your normal routine the following day.
Missing one dose may cause a brief return of symptoms but is not dangerous.
Progesterone
Continuous progesterone (taken every day)
Take the missed dose as soon as you remember.
If it is nearly time for the next dose, skip the missed one and continue as normal.
Sequential progesterone (taken for part of the month)
If you miss a dose during the progesterone phase, take it when you remember.
If it is close to the next scheduled dose, skip the missed one and continue the cycle.
One missed dose is unlikely to cause problems. The main aim is to stay consistent overall.
Testosterone
Apply the missed dose when you remember.
Resume your usual routine the next day.