You get eight minutes, a prescription, and a leaflet that lists every side effect ever reported in alphabetical order. Nobody tells you what a good response actually looks like, how long to wait for it, or what to do in week three when you feel worse than you did before you started.
That gap is where most people give up on hormone therapy. Not because it failed, but because nobody defined success, so there was no way to tell.
This is a plain explanation of what the options are, why the route into your body matters more than the brand on the box, what changes on what timescale, which side effects settle and which ones mean go back sooner, and what to bring to the review appointment.
It is general information and not medical advice. Every decision below belongs to you and a qualified clinician who knows your history.
Start by Naming the Target
Before anything else, write down the two or three symptoms you actually want fixed, and how bad each one is right now.
This sounds trivial. It is the single most useful thing you can do, and almost nobody does it.
Twelve weeks from now you will be trying to answer the question "is this better?" from memory, while living inside a body that was already unpredictable. Memory is the worst possible instrument for this. It flattens the good weeks, it overweights the last bad night, and it cannot tell you whether the flashes went from fourteen a day to five or from fourteen to twelve.
Pick your targets, rate them, and date the page. Then you have a baseline, and everything that follows becomes measurable instead of impressionistic. If you are not yet sure whether what you are experiencing is the transition at all, the signs and stages piece covers that question first.
What HRT Actually Consists Of
Modern hormone therapy is not one drug. It is a combination, assembled from two components and occasionally a third.
Oestrogen is the part doing the work on the symptoms most people come in for: hot flashes, night sweats, disturbed sleep, and a good deal of the mood and cognitive turbulence that travels with them.
A progestogen is added for anyone who still has a uterus. Its job is not symptom relief, it is protecting the endometrium from the thickening that unopposed oestrogen causes. This part is not optional and not negotiable if you have a uterus. Skipping it is the one genuinely dangerous shortcut in this whole area.
Testosterone is sometimes added, most often for persistent low sexual desire that has not responded once the oestrogen is settled. Availability and licensing vary enormously by country, and in many places it is prescribed off label against a specific guideline.
Two terms you will meet immediately, and they are not the same thing:
- Body identical hormones are regulated pharmaceutical products with a molecular structure matching what your ovaries made: estradiol, and micronised progesterone. These are standard prescriptions.
- Compounded bioidentical hormones are mixed to order by a compounding pharmacy, often marketed with saliva testing and personalised blends. Major menopause societies advise against them, because the products are not subject to the same regulatory testing for dose consistency, purity or endometrial safety. The marketing borrows the credibility of the first category to sell the second.
Route Matters More Than Brand
Oestrogen can be delivered several ways, and the difference is not about convenience.
| Route | Form | Notes |
|---|---|---|
| Transdermal | Patch, gel, spray | Absorbed through skin, bypasses the first pass through the liver. Guidance in several countries treats this route as not carrying the raised clot risk seen with oral |
| Oral | Tablet | Simple and familiar. Passes through the liver first, which is where the clot risk difference originates |
| Vaginal | Cream, pessary, ring | Local treatment for vaginal and urinary symptoms. Very low systemic absorption |
The transdermal versus oral distinction is worth raising yourself if it does not come up. It matters more if you have migraine with aura, a personal or family history of clots, a raised BMI, gallbladder disease or certain liver considerations.
Practical differences inside the transdermal group are real too. Patches deliver steadily but can lift in heat or after swimming, and a twice weekly patch can produce a dip in the hours before the change. Gel and spray let the dose be adjusted more finely, but have to dry and can transfer to someone else's skin before they do.
The Progestogen Half, and Why It Has Two Shapes
If you have a uterus, the oestrogen comes with endometrial protection, and it takes one of two shapes depending on where you are in the transition.
Cyclical, also called sequential. Progestogen for part of each month, commonly around twelve to fourteen days, which produces a predictable monthly bleed. This is the usual starting regimen when you are still having periods, because continuous progestogen against a background of ovaries that are still firing tends to produce chaotic unscheduled bleeding.
Continuous combined. Both hormones every day, aiming for no bleed at all. This is generally used once periods have stopped, or after a period of time on a cyclical regimen.
The progestogen itself also varies. Micronised progesterone is the body identical option, taken at night because it is mildly sedating, which some people find is a benefit in its own right. Synthetic progestogens are effective and sometimes preferred for specific reasons. A hormonal coil is a third route: it delivers progestogen locally to the endometrium, provides contraception at the same time, and is licensed for endometrial protection for a defined number of years, which varies by country and product.
That last point is worth flagging because progestogen intolerance is one of the most common reasons people abandon HRT. Low mood, bloating, breast tenderness and irritability in the progestogen days are a known pattern. It is frequently solvable, by changing the type, the route or the regimen, but only if you report it as a specific pattern rather than as "the HRT does not agree with me".
Vaginal Oestrogen Is a Separate Decision
Dryness, soreness, pain with sex and recurrent urinary symptoms are driven by local tissue change, and they are the symptoms least likely to improve on systemic HRT alone.
Local vaginal oestrogen is a different treatment with a different profile: very low systemic absorption, generally no progestogen required alongside it, and it can be used on its own or in addition to systemic HRT. It is also slow. Expect improvement over weeks and full benefit closer to three months, and note that unlike flashes it does not stay fixed after you stop, because the tissue change returns when the treatment does.
This one gets left unmentioned in appointments constantly, on both sides of the desk. If it applies to you, raise it explicitly.
The Timeline: What Changes When
This is the part nobody writes down, and the reason people quit at week six.
| Timescale | What typically changes |
|---|---|
| Week 1 to 2 | Little symptom change. Early side effects most likely here: breast tenderness, nausea, headache, a bloated feeling |
| Week 2 to 4 | Hot flashes and night sweats usually start easing. Sleep often follows |
| Week 4 to 12 | Fuller vasomotor effect. Mood and anxiety improve more gradually. Bleeding pattern begins to settle |
| Month 3 to 6 | The realistic point to judge the current dose. Unscheduled bleeding usually settled by here |
| Month 3 onwards | Vaginal symptoms on local oestrogen reach full effect |
Two things follow from that table.
The first is that **judging a dose at four weeks is judging it too early**, and a lot of people conclude HRT does not work for them at exactly the point it has not had time to.
The second is that **the side effects front load and the benefits back load**. Weeks two and three can genuinely be the worst of it, which is a cruel design, and it is why knowing the shape of the curve in advance changes how many people stay on long enough to find out whether it helps.
What "Working" Actually Looks Like
Working is not the absence of every symptom. It is a meaningful reduction in the ones you named at the start, at a dose whose side effects you are willing to live with.
Three concrete things to look at around the twelve week mark:
- Frequency. Are the target symptoms happening less often than your baseline page says they were? Half as often is a real response, not a failure to reach zero.
- Severity. When they do happen, are they smaller? A flash you notice is not the same event as a flash that soaks a shirt in a meeting.
- Function. Are you sleeping through more nights, working a normal day, not cancelling things? This is the one that actually matters, and the one most likely to be missing from a symptom diary that only counts flashes.
Watch for two specific patterns, because they point at the fix rather than at failure:
- Symptoms that reliably return in the day or two before a patch change point at the delivery schedule.
- Symptoms that appear at the same point in a cyclical regimen every month point at the progestogen phase.
Neither is "HRT is not working for me". Both are specific, fixable observations, and they are only visible in a record kept against dates.
Side Effects: What Settles, What Does Not
Common in the first weeks and usually settling: breast tenderness, nausea, headaches, leg cramps, bloating, a feeling of fluid retention, and skin reaction under a patch.
Reasons to go back rather than wait it out:
- Unscheduled bleeding that is still happening after around six months, or bleeding that starts again after the pattern had settled
- Any bleeding after twelve months without periods
- Low mood or irritability that starts with the progestogen phase and does not settle over a couple of cycles
- New severe headache or migraine with visual aura
- Calf pain or swelling, chest pain or breathlessness, which need urgent attention rather than a routine appointment
And the thing worth saying plainly: the first prescription is a starting point, not a verdict. Doses get adjusted, routes get switched, progestogens get swapped. Somebody who tried one product for six weeks in 2019 and concluded HRT was not for them may simply have been on the wrong regimen for their stage.
Non-Hormonal Options Are Real Options
Hormone therapy is not the only effective treatment, and it is not appropriate for everyone. The alternatives worth knowing exist:
- Cognitive behavioural therapy has a decent evidence base specifically for hot flashes and for the insomnia that comes with them, and it does not compete with hormones. It changes the distress and the sleep response rather than the flash itself.
- NK3 receptor antagonists are a newer non-hormonal drug class that acts on the brain's temperature control pathway, approved for vasomotor symptoms in a number of countries. Ask whether one is available where you are.
- Certain antidepressants, some blood pressure and nerve pain medications, are used off label for flashes with modest but genuine effect.
- Sleep, alcohol and temperature management will not fix hormonal turbulence, but they alter how bad a bad night gets. If your main complaint is waking in the small hours, the piece on 3am waking covers the non-hormonal mechanics of that specific pattern.
Risk, Without the 2002 Panic and Without the Sales Pitch
Two decades of conversation about HRT still carry the shadow of one trial whose headline was widely misread. The population studied was on average well past sixty, using an oral formulation that is not the standard first choice today, and the relative risk figures that made the front pages were attached to small absolute numbers. Prescribing collapsed, and a generation of women went untreated on the strength of a number that did not apply to them.
The correction is not that HRT is risk free. It is that risk depends on your age, how long since your final period, the route, the specific progestogen, the duration, and your own history.
What is reasonably settled:
- Starting before sixty, or within about ten years of the final period, has a more favourable balance than starting long after
- Oral oestrogen carries a clot risk that transdermal oestrogen is not associated with in the same way
- Combined oestrogen and progestogen is associated with a small increase in breast cancer risk that relates to duration of use, and oestrogen alone sits lower
- Local vaginal oestrogen is a different conversation from systemic treatment because so little is absorbed
Your personal numbers are not in an article. They come from someone who can see your history, and they are worth asking for in absolute terms rather than percentages, because "a 30 percent increase" and "an extra few cases per thousand women over five years" describe the same thing and feel nothing alike.
What to Bring to the Review
Four things, and they take one page:
1. The baseline you wrote down before starting, with today's ratings next to it
2. Your actual adherence, honestly, including the patch you forgot for two days
3. Any pattern tied to timing: before a patch change, during the progestogen phase, at a particular point in a cycle
4. One sentence on what you want next: this dose, a higher one, a different route, or a different progestogen
That page turns a defensive eight minute appointment into a working one. The clinician stops trying to extract a history and starts adjusting a treatment.
Where Alva Fits
Alva exists because this is a tracking problem wearing a medical costume. The information that makes the review appointment useful is exactly the information a human brain is worst at retaining.
It logs 40 symptoms rather than just flashes, so brain fog, joint pain, sleep and mood are in the same record as the vasomotor ones. It handles hormone therapy properly, which is unusual: patches, gels, sprays, tablets, pessaries, rings and implants, cyclical regimens such as twelve days on and sixteen days off anchored and repeating, twice weekly patch schedules with a site rotation prompt, adherence over any range, and a dose history that keeps every past regimen intact. That last detail is the one that matters for the question in this article, because "is this working" is really "is this working better than what I was on before", and that comparison needs the old regimen to still be there.
It also refuses to predict. In perimenopause a cycle app that projects a date is guessing, so Alva shows the observed range instead: your last six cycles ran 24 to 58 days, it has been 39 days. No red warning on a long gap, no use of the word late.
Six on-device analyses describe patterns, including treatment response, and every card shows the sample size and date range it used. One tap exports three months as a clinical PDF: cycle table, variability, ranked symptoms with sparklines, current regimen and adherence, legible printed in greyscale.
What it does not do:
- It does not diagnose, and it does not recommend a treatment. It is a record and a description of patterns in that record. It is not a medical device.
- A pattern is not a cause. Symptoms clustering in the progestogen phase is an observation to raise, not a mechanism you have proved.
- It cannot tell you your personal risk profile. Nothing outside a consultation can.
- Three months of data on a turbulent body supports modest conclusions. It is evidence for a conversation, not a verdict.
There is no account, no sign in, and no advertising or analytics code in the app. Entries stay on your iPhone and sync only through your own iCloud. Free covers unlimited logging, medication reminders, dose ticking and the last 30 days. Pro adds full history, insights, charts and export.
The Short Version
- Write down your two or three target symptoms and rate them before you start. Without a baseline you cannot answer the only question that matters in twelve weeks
- HRT is oestrogen, plus a progestogen if you have a uterus, occasionally plus testosterone. The progestogen is endometrial protection, not symptom relief, and it is not optional
- Route matters. Transdermal oestrogen bypasses the liver and is not associated with the clot risk seen with oral, which makes it a real conversation to have
- Still cycling usually means a cyclical regimen with a monthly bleed. Continuous combined comes later
- Vaginal oestrogen is a separate treatment for separate symptoms, slow to work, and easy to leave unmentioned in an appointment
- Flashes and sleep typically improve in two to four weeks, the fuller effect lands around three months, mood is slower. Side effects front load, benefits back load
- Judging a dose at four weeks is judging it too early. Twelve is the realistic review point
- Symptoms returning before a patch change or during the progestogen phase are fixable patterns, not treatment failure
- Non-hormonal options exist and work: CBT for flashes and insomnia, the newer NK3 antagonist class, some off label medications
- Ask for your risk in absolute numbers, not percentages, and remember HRT is not contraception
- Bring one page to the review: baseline versus now, real adherence, timing patterns, and what you want next