HRT
HRT Monitoring & Review Schedule
What to expect at your 12-week, 6-month and annual HRT reviews in the UK.
Reviews are about symptom control, side effects, blood pressure and lifestyle — not routine hormone tests. Knowing the rhythm helps you get the best from every appointment.
Good HRT prescribing is not ‘find the right patch and see you in a year’. It is an active, iterative process — small adjustments in dose, route and progestogen delivery based on how you feel, what you notice, and how life is going. NICE NG23 is emphatic on one point that surprises many women: routine blood monitoring is not required for most women on HRT. Symptoms and safety are the currency of a review, not FSH and oestradiol levels. Understanding what a good review looks like — and what should trigger one sooner — makes the difference between HRT that transforms life and HRT that ‘isn’t really working’.
The review rhythm we use in clinic
- 12-week review after starting or changing a regimen — the earliest fair moment to judge response.
- 6-month review to confirm stability and pick up bleeding pattern issues.
- Annual review thereafter, sooner if anything changes.
- Additional review 6–8 weeks after any dose or route change.
- For women on testosterone: 3-monthly bloods for the first year, then every 6–12 months.
What we cover at every review
- Symptom score for the top 3 issues before HRT and now (0–10 scale).
- Sleep quality, mood, energy, cognition, libido and joint symptoms — sometimes improvement is uneven, which is normal.
- Bleeding pattern — expected on sequential regimens, should stop by 6 months on continuous combined regimens.
- Side effects: breast tenderness, bloating, headaches, skin reactions to patches, gel absorption issues.
- Blood pressure, weight, waist circumference; annual BMI trend matters more than a single reading.
- Breast awareness and NHS screening attendance.
- New medications or health conditions that might interact.
- Lifestyle levers: exercise, alcohol, sleep, diet, stress load.
Why routine blood tests are usually not needed
- FSH doesn’t reliably guide HRT dosing — levels fluctuate widely, and once on oestrogen, FSH results are hard to interpret.
- Oestradiol levels correlate poorly with symptom response — some women feel excellent at low levels, others need higher doses to feel like themselves.
- The exception: high-dose transdermal users whose symptoms aren’t controlled, where an oestradiol level helps identify absorption issues.
- NICE NG23: ‘Do not routinely measure hormone levels to diagnose perimenopause or menopause in women aged 45+’ — and by extension, monitoring is symptom-based.
When blood tests genuinely help
- Suspected premature ovarian insufficiency (POI) under 40 — FSH x2, oestradiol, prolactin, thyroid, AMH.
- Suspected menopause in women aged 40–45 where diagnosis affects treatment.
- Testosterone therapy — baseline total testosterone and SHBG, then 3–6 monthly to ensure levels stay in female physiological range.
- High-dose HRT users with poor response — an oestradiol level identifies malabsorption.
- Women on oestrogen-only HRT with a uterus (never appropriate — this is a safety review, not a monitoring test).
- New symptoms suggestive of thyroid disease, iron deficiency or diabetes.
Safety checks we do not skip
- Blood pressure at every review.
- Mammogram every 3 years from 50–71 through NHS Breast Screening.
- Cervical screening as per NHS schedule.
- Bone health: DEXA scan around 60, sooner with risk factors.
- Cardiovascular risk: QRISK3 score periodically; lipids, HbA1c as clinically appropriate.
- Bleeding after menopause, or unexpected bleeding on continuous combined HRT beyond 6 months — always investigated.
What to bring to your review
- A short symptom score for the top 3 issues (before HRT and now).
- A note of any bleeding, headaches, mood shifts or side effects.
- Any changes in health, medications, family history or lifestyle.
- Blood pressure readings if you have a home monitor.
- Your questions, written down — 60 minutes goes quickly.
Red flags that mean review sooner, not later
- Heavy or persistent bleeding beyond 6 months of continuous combined HRT.
- Any bleeding at all in a woman genuinely postmenopausal on oestrogen-only HRT (with a uterus — this should not be prescribed).
- Severe headaches with visual changes.
- One-sided calf swelling, chest pain, sudden breathlessness.
- A new breast lump, skin change or nipple change.
- Sustained blood pressure rise above 140/90 mmHg.
Key takeaway
Good HRT care is a conversation, reviewed at 12 weeks, then 6 months, then annually — with routine blood tests almost never needed and safety checks (blood pressure, screening, bleeding) that are non-negotiable.
How Dr Awal approaches this in clinic
Every consultation starts with your full story — symptoms, cycle, medical history, family history and what you've already tried. From there we look at whether hormonal treatment, non-hormonal options, lifestyle changes or a combination will give you the best result, and we tailor the plan to your age, risk factors and preferences.
- A detailed 60 minute first appointment — no rushed 10-minute slots.
- Evidence-based recommendations aligned with NICE NG23 and BMS guidance.
- Body-identical HRT considered first-line where appropriate.
- Shared-care letters sent to your NHS GP so treatment can continue affordably.
- Follow-up at 3 months to fine-tune your regimen and address side effects.
- Ongoing annual reviews so your plan evolves with you.
Common questions we hear about this
Do I need to be at a certain age to be seen?
No. We see women in early perimenopause (often late 30s and 40s), through post-menopause and beyond. Age alone doesn't decide whether treatment is right — symptoms, health history and goals do.
Will my GP continue the prescription?
In most cases yes. After your consultation we send a detailed shared-care letter with the diagnosis, treatment plan and rationale so your NHS GP can prescribe on the NHS. Not every practice accepts shared care — we'll discuss this in your appointment.
What if I've tried HRT before and it didn't suit me?
Very common — often the type, dose or route wasn't right rather than HRT itself. We review what you've tried, why it didn't work, and adjust accordingly. Many women who thought HRT wasn't for them do well on a different preparation.
How long will I need to stay on treatment?
There is no set upper time limit for HRT. Current BMS and NICE guidance supports continuing HRT for as long as the benefits outweigh the risks for you personally. We review this together every year so you stay in control of the decision.
Where do you see patients?
All consultations at Pause and Co Healthcare are conducted securely via video, allowing us to support patients anywhere in the UK. Prescriptions and shared care arrangements are managed in the same way, regardless of your location.
About the author
Dr Nadira Awal is a British Menopause Society Advanced Menopause Specialist with 15+ years' NHS and private experience. She holds the BMS Advanced Certificate in Menopause Care, sits on the BMS Programme Planning Group, and advises the UK Government Menopause Strategy Group. Read her full profile.
Sources & further reading
General information only — not a substitute for personalised medical advice. Always speak to your GP or a menopause specialist about your own situation.
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