When HRT Doesn't Work: The Functional Fix You Haven't Tried Yet

Ah, menopause. If you’re somewhere between your mid-40s and mid-50s, you’ve likely hit that point in your life when your hormones seem to have gone haywire once again. Maybe you were battling hot flashes that left you drenched at 3 a.m. or experienced brain fog so thick you couldn't remember why you walked into a room. You want your energy back. You want balance, and to reclaim that spark you used to have.

You started hormone replacement therapy (HRT) to feel like yourself again because you’ve been told that it was supposed to be the magic elixir. Yet somehow, instead of feeling better, you're bloated, irritable, exhausted, and wondering if you made a mistake. You might even be blaming your body, thinking maybe you're just one of those women who "can't handle" hormones.

Here's the truth bomb: HRT isn't always the problem. But how it's prescribed, dosed, and delivered might be. And, more importantly, any prior and current underlying issues left unaddressed before you started HRT might be sabotaging everything.

We are going to break down why standard hormone therapy fails so many women, address questions you need to ask to get the answers you need, and explore alternative functional medicine options that might offer the balance and results your body needs.

The Top 5 Reasons Your HRT Isn't Working

There are a number of reasons why HRT might not be working for you. The following are some of the most common ones.

1. Everything All at Once

Walking into an appointment and leaving with prescriptions for estrogen, progesterone, and testosterone all at once is like trying to conduct an orchestra when everyone starts playing different songs simultaneously. It's chaos.

Your body needs a staggered, foundational approach. Starting with one hormone allows you to see how your system responds before layering on more. Maybe your body's screaming for progesterone first to calm cortisol and support sleep. Or perhaps estrogen is the missing piece that'll finally lift that fog. When you pile them all on at once, you can't tell what's helping and what's hurting—and your symptoms become a confusing mess.

2. Dosing Issues

Much like with Alice in Wonderland reduced hormones won't move the needle on your symptoms. Too high of an amount creates new problems entirely. When estrogen doses run too high, you might see bloating, breast tenderness, anxiety, and mood swings. Too low? The hot flashes persist and energy stays flat.

Here's where functional medicine differs from conventional prescribing: we don't just look at whether you're in the "normal" lab range. We listen to your body's biofeedback. How are you sleeping? What's your energy like at 3 p.m.? Are you holding water weight or feeling wired at night? Your lived experience matters more than a number on paper, and your dose should reflect that.

3. Incompatible Delivery Method

There are plenty of different delivery methods for HRT: creams, patches, pills, injections, troches, etc. While it's easy to look at them from the perspective of convenience or preference, it is more important to consider absorption, metabolism, and how your unique body processes hormones.

For example, while topical estrogen might give one woman mental clarity, it might cause uncomfortable bloating in another. Oral progesterone can make you sleepy (which is great at bedtime), while transdermal might keep you alert but not address sleep issues. Even timing matters—taking progesterone in the morning versus at night can create totally different outcomes. Your delivery method should take into account and match your metabolism, lifestyle, and symptoms, not just what's most commonly prescribed.

4. Your Detox Pathways Are Blocked or Dragging

Estrogen doesn't just go into your body and magically transform you. It must be broken down, metabolized by your liver, and excreted through your gut. If those pathways are sluggish (such as by constipation, poor liver function, or gut dysbiosis), estrogen recirculates instead of exiting. This creates estrogen dominance even when you're on a reasonable dose.

Wondering if your detox pathways need support? Headaches, sore or tender breasts, mood swings, heavy periods, or breakthrough bleeding are all signs your body might not be detoxing properly.

5. You Never Addressed Root Causes First

Blood sugar chaos, thyroid imbalance, chronic stress, and gut inflammation don't just coexist with hormone problems—they drive them. Putting HRT on top of a dysregulated system is like pouring water into a leaky bucket. It might help temporarily, but it won't hold.

This is why functional testing and foundational work matter so much. Before we add hormones, we need to know: Is your thyroid sluggish? Is your cortisol pattern healthy? Are you digesting and absorbing nutrients? Is inflammation running wild in your gut? When these foundations are shaky, HRT can't do its job properly—and you end up frustrated and feeling worse.

When In Doubt, Ask Your Practitioner

Before you throw in the towel on HRT completely, have a candid conversation with your doctor. The following are useful questions that will help provide clarity:

• "Which hormone did we start with—and why?"
• "Was my dose based on symptoms or just numbers?"
• "How are we tracking hormone metabolism?" (Ask about DUTCH testing or estrogen metabolites)
• "Should we consider changing the delivery method?"
• "Are we supporting detox and drainage while I'm on HRT?"

Remember this: HRT doesn't fix root causes—it only works well when your foundations are solid.

Seeking Out Functional Support to Make HRT Work for You

When administered properly for your specific body’s needs, HRT can be a game changer. But it’s not the be all, end all. Before or alongside HRT, it’s important to prioritize the following foundations:

• Liver support: Support liver detoxification by loading up on cruciferous vegetables and considering supplements like DIM or calcium-D-glucarate.
• Gut health: Cut down on inflammatory foods like processed sugars and alcohol and replace them with those rich in fiber, probiotics, and anti-inflammatory properties that help your body eliminate hormones properly instead of recirculating them.
• Blood sugar stability: Get your blood sugar stable with protein-heavy meals, morning sunlight, and stress regulation, all of which keep insulin and cortisol from wreaking havoc on your hormone receptors.
• Mineral repletion: Magnesium, zinc, and B vitamins are cofactors in hormone production and metabolism—without them, nothing works optimally. Get your levels tested and supplement where needed.
• Test, don’t guess: Get a full picture with functional testing that will provide cortisol mapping, thyroid panels, and hormone metabolite testing.
• Your hormones are basically your body’s messengers, giving you signals of when things are wrong. Listen to them.

Making HRT Work for You

You're not failing HRT. And it is possible HRT isn't failing you. It might simply be problems in your body’s foundation. If so, it is time to identify root causes and find a strategy that works with your body, not against it. That means creating a plan that is smarter and more specific to you. I can help guide you on your journey to get the full picture you need of your overall health so you can identify and address any underlying issues that might be compromising HRT’s effectiveness and start from solid footing.