Menopause symptoms and hormone replacement therapy (HRT) side effects can overlap, which can make it difficult to tell what is causing a new or changing symptom. Hot flushes, night sweats, sleep problems, low mood, anxiety and vaginal dryness are commonly associated with perimenopause and menopause. HRT is used to relieve many of these symptoms, but the oestrogen and progestogen used in HRT can also cause effects such as headaches, breast tenderness, nausea, mood changes and unexpected vaginal bleeding or spotting.
Timing can provide useful clues, but it cannot confirm the cause on its own. A symptom that was present before starting HRT may be more likely to be related to menopause, while a new symptom that begins soon after starting HRT or changing the dose, product or method of administration may be medicine-related. Some HRT side effects improve as the body adjusts to treatment.
If you are unsure, do not assume that every symptom is caused by either menopause or HRT. Other medicines, supplements and unrelated health conditions may produce similar symptoms. Keep track of what is happening and discuss persistent, severe or unusual symptoms with a doctor or pharmacist.
For broader information about hormonal medicines, visit the Women’s Health and Hormonal Medicine hub or see the related parent guide.
How menopause Symptoms vs HRT Side Effects can be linked to medicines or supplements
One reason the distinction can be confusing is that menopause and HRT may affect some of the same parts of the body.
During perimenopause and menopause, changing hormone levels can contribute to symptoms including hot flushes, night sweats, disrupted sleep, mood changes, anxiety, problems with memory or concentration, reduced sex drive and vaginal dryness. Menstrual patterns may also become irregular during perimenopause.
HRT replaces hormones that fall during menopause and can improve many of these symptoms. Oestrogen is the main component used to relieve menopause symptoms, while people who still have a womb will generally also need a progestogen to protect the lining of the womb. Different formulations are available, including tablets, patches, gels, sprays and vaginal preparations.
Possible timing clues
The timing of a symptom is often one of the most useful things to discuss with a healthcare professional.
A symptom may be more consistent with menopause when it:
- started before HRT was introduced;
- follows an existing pattern of menopause symptoms;
- fluctuates alongside other symptoms such as hot flushes or changes in periods; or
- improves after HRT begins.
A symptom may be more suspicious for an HRT side effect when it:
- starts after a new HRT product is introduced;
- appears after the dose is changed;
- begins after switching from one formulation or method to another;
- occurs in a repeating pattern linked to when a medicine is taken or applied; or
- improves or worsens following a clinician-supervised treatment adjustment.
These are clues rather than proof. For example, low mood, headaches and hair changes can occur around menopause but may also be reported during HRT treatment.
Medicines and product categories that may be associated with this symptom
The exact side effects depend on which hormones and formulations you use.
Oestrogen-containing HRT
Oestrogen tablets, patches, gels and sprays can cause side effects including headaches, breast pain or tenderness, nausea, unexpected vaginal bleeding or spotting, mood changes, leg cramps, mild skin reactions, diarrhoea and hair loss. Many people have no side effects or only mild effects, and some symptoms improve as the body becomes accustomed to treatment.
A local reaction can also matter. For example, itching or a rash limited to the area where an HRT patch, gel or spray is applied may point towards the treatment rather than menopause itself.
Progestogen and combined HRT
Progestogens can also cause headaches, breast tenderness, nausea, tiredness, dizziness, mood changes, diarrhoea, skin symptoms or acne. People using combined HRT may therefore experience effects related to either the oestrogen or progestogen component.
Bleeding patterns can also change depending on whether HRT is sequential or continuous. This is why it is important to tell your doctor exactly which product and regimen you are using rather than simply saying that you take “HRT”.
Vaginal oestrogen and other HRT formulations
HRT is not a single medicine. Vaginal oestrogen, systemic oestrogen, combined preparations, progesterone products and treatments such as tibolone have different side-effect profiles.
Check the patient information leaflet supplied with your specific product and ask a pharmacist if you are unsure which ingredients it contains.
Other medicines and supplements
Some people use non-hormonal medicines or complementary products to manage menopause symptoms. These products can also cause side effects or interact with other medicines.
Herbal products marketed for menopause, including remedies containing ingredients such as black cohosh or red clover, should not automatically be assumed to be safer because they are described as “natural”. Evidence about the effectiveness and safety of some complementary menopause products is limited, and interactions with medicines are possible.
If symptoms appeared after starting any prescription medicine, over-the-counter product, vitamin, herbal remedy or supplement, include it when discussing your symptoms with a healthcare professional.
Red flags: when this symptom may need urgent medical attention
Most HRT side effects are not medical emergencies. However, certain symptoms require prompt or immediate assessment because they may indicate a serious problem rather than an ordinary menopause symptom.
Get urgent medical help for possible emergency symptoms
Seek immediate medical attention if you develop symptoms such as:
- difficulty breathing or severe shortness of breath;
- sudden swelling of the lips, tongue, mouth, face or throat;
- chest pain together with breathlessness;
- sudden difficulty speaking;
- sudden weakness or difficulty moving an arm or leg;
- one side of the face suddenly drooping;
- fainting or being difficult to wake; or
- signs of a severe allergic reaction.
These symptoms can occur with serious conditions including anaphylaxis, pulmonary embolism, heart problems or stroke and should not be managed as routine HRT side effects at home.
Pain, redness or swelling affecting one leg, particularly the calf, also needs prompt medical assessment because it can be a sign of deep vein thrombosis.
Do not ignore unusual or persistent bleeding
Irregular bleeding or spotting can occur during the first few months after starting some types of HRT. NHS guidance notes that it commonly settles within the first several months. However, bleeding that becomes heavier, continues beyond about six months after starting HRT, or begins unexpectedly after a period without bleeding should be assessed by a healthcare professional.
Any unexplained vaginal bleeding after menopause should also be medically assessed rather than assumed to be a harmless menopause or HRT symptom.
New breast lumps, nipple changes, skin dimpling or other persistent breast changes should also be discussed with a doctor.
What to track before speaking to a doctor or pharmacist
A simple symptom record can make it easier to work out what changed and when.
Write down:
- the symptom you are experiencing;
- when it first started;
- how often it happens;
- how long each episode lasts;
- whether it is getting better, worse or staying the same;
- when you started HRT;
- the exact HRT product and strength;
- whether you use tablets, patches, gel, spray or another formulation;
- any recent changes in dose or product;
- where you are in your HRT treatment cycle, if applicable;
- any vaginal bleeding or spotting and how heavy it is;
- all other prescription medicines;
- over-the-counter medicines, vitamins and supplements;
- any other symptoms occurring at the same time; and
- anything that seems to trigger or relieve the symptom.
It can also help to note whether the symptom existed before HRT. For example, if night sweats were frequent before treatment and have gradually improved, that pattern may be different from a new headache that appeared shortly after a dose change.
Do not worry about determining the cause yourself. The purpose of tracking is to give your doctor or pharmacist better information for assessing possible medicine-related causes.
You can also compare symptoms with the broader side effect symptoms A-Z.
What not to do without medical advice
Do not stop prescription HRT, alter your dose or change the way you use it solely because you suspect a side effect without discussing the situation with your doctor or pharmacist.
If side effects are troublesome, a clinician may sometimes consider changing the dose, changing the type of HRT or switching the route of administration, such as from tablets to a patch. The appropriate option depends on the individual and should be decided with professional guidance.
You should also avoid:
- doubling a dose because you think HRT is not working;
- using another person’s HRT;
- adding herbal or hormonal products without checking for interactions;
- assuming persistent symptoms are “just menopause”;
- assuming every new symptom must be caused by HRT; or
- delaying urgent medical attention because you are waiting to see whether a serious symptom settles.
HRT can be very effective for symptoms such as hot flushes, night sweats, menopause-related sleep problems, low mood and vaginal dryness. Its benefits and risks vary according to factors including age, symptoms, type of HRT and individual health risks, so decisions about treatment should be personalised.
Related side-effect guides and reporting options in South Africa
If you are trying to understand whether another medicine could be contributing to your symptoms, see the wider guide to medication side effects.
If you suspect that HRT or another medicine has caused an adverse reaction, you can also discuss reporting it with your doctor or pharmacist. In South Africa, the South African Health Products Regulatory Authority (SAHPRA) allows members of the public and healthcare professionals to report suspected adverse drug reactions through its Med Safety App.
For step-by-step local information, see how to report side effects in South Africa.
Reporting a suspected reaction does not necessarily mean the medicine has been proven to have caused it. Pharmacovigilance reports help regulators monitor medicine safety and identify potential safety signals across many reports.
Frequently asked questions
Is this a common side effect?
It depends on the symptom and the specific HRT product. Headaches, breast tenderness, nausea, mood changes and spotting or unexpected bleeding are among the effects reported with HRT, but not everyone experiences them. Menopause itself can cause some similar symptoms.
How long can HRT side effects last?
Many mild HRT side effects improve during the first few weeks or months as the body adjusts. If a side effect is severe, continues beyond the expected adjustment period or is becoming more troublesome, speak to your doctor or pharmacist rather than simply waiting for it to disappear.
Should I stop HRT if I think it is causing side effects?
Do not stop or change prescribed HRT without medical advice unless an emergency healthcare professional instructs you to do so. A doctor may be able to adjust the dose, formulation or method of administration if a side effect is suspected.
When should I seek help?
Speak to a doctor or pharmacist if a symptom is persistent, worsening, difficult to manage or began after starting or changing HRT. Seek urgent medical attention for chest pain with breathlessness, stroke-like symptoms, severe breathing difficulty, swelling of the face or throat, fainting or other signs of a serious allergic reaction.
Medical safety note: This information is for general education and cannot determine whether an individual symptom is caused by menopause, HRT or another health condition. A doctor or pharmacist can review your symptoms, medical history and exact medicines. Seek immediate medical help for severe or rapidly worsening symptoms.