The gel that took the nights back 2 years ago is doing nothing this month. She has restarted it twice, changed the time she puts it on, and still wakes at 3. The search she types is HRT stopped working, as if the treatment has a will of its own. What she is actually asking is whether she has to live like this again, or whether someone will sit down and look at what has changed.
The short version is this. If the treatment that used to help has gone quiet, the first move is usually to adjust it, not to abandon it. A coil that has reached the end of its job is a different problem from a dose that is now too low. Blood tests can help when the picture is messy. They are not a reason to withhold treatment while we wait for a number.
Chest pain, signs of a stroke, severe breathlessness, heavy bleeding, a severe allergic reaction or symptoms of sepsis need 999 or A&E immediately. A clinic appointment is the wrong door for those.
What to do when HRT stopped working?
Symptoms first. Numbers second. That is the order in clinic, and it is the order NICE uses for women over 45. The decision is clinical. A laboratory printout does not get a veto.
People arrive expecting a verdict. They have often been told that their levels are “fine”, or that they are now “too old”, or that they should stop because 5 years is enough. None of those sentences is an examination. What I look at in clinic is whether the method still matches the person in front of me.
Gel that never absorbed because it went on recently moisturised skin is not a failure of hormones. A patch that spends half the week in the shower tray is not a failure of hormones. A coil inserted 6 years ago that has quietly run out of the part it was contributing is not a reason to give up on the whole idea. It is a reason to look.
What does a GP actually review?
I start with when it last helped, and what “helped” meant. Sleep. Flushes. Mood. Joints. The foggy mid afternoon. Comfort with sex. Then I ask how it is actually used, not how the box says it should be used. Site, timing, whether the patch stays on, whether the gel is left to dry, whether doses have been doubled on a bad week and skipped on a good one.
Then the bleed. A new bleed after months of quiet is a different conversation from a bleed that has always been there. A coil raises its own questions: when it went in, whether the threads are felt, whether there is pain, whether it may have shifted. A coil problem is not solved by putting more gel on the arm.
I look at the rest of the picture, because the piece most people miss is that flushes and poor sleep have more than one author. Thyroid disease. Iron that has been low more than once. Alcohol that has crept up. A tablet started for blood pressure. Weight change. A mood that has dropped underneath the sweats. From our practice, the woman who says the treatment has failed is quite often describing a second problem sitting on top of a first one that is still doing some of its job.
Examination is unhurried. Blood pressure. Pulse. Weight. The abdomen if there is pain or a coil question. A speculum if the threads need checking or the bleed needs a look. Breasts if that is part of the review she has come for. Nothing is rushed, because medicine done properly takes time.
Bloods have a place. They help when the menopause has come early, when the womb and ovaries are no longer there and the story is unclear, when we are sorting thyroid or iron from the hormone picture, or when previous advice has been a mess of conflicting printouts. They do not sit in front of treatment in an ordinary woman over 45 with a classic story. I say so if hers is the sort of case where a number will not change what we do this week.
Adjustment is ordinary work. Change the dose. Change the route. Replace a coil that has timed out. Treat the thyroid or the iron if that is what we found. Sometimes the plan stays and we wait 6 to 8 weeks, because some of this settles slowly and fiddling every 10 days helps nobody. I do not know yet, let us look again in 6 weeks, is a legitimate sentence in this room.
What I will not do is promise that symptoms will vanish, or that one visit will finish the story. That time is the point. A review is a review. It is not a guarantee.
When should I come in sooner?
Most of this can wait for a booked clinic slot. A few things should not.
- A sudden, heavy bleed, or a bleed after the menopause that is new, soaking through, or making you dizzy.
- Chest pain, a swollen painful calf, or sudden breathlessness. Those need 999 or A&E, not a hormone conversation.
- A breast lump, new nipple change, or a gland in the armpit you have not had checked.
- Severe low mood, or thoughts of not wanting to be here. That is same day care, and it may be 999 or A&E rather than us.
- Migraine that has changed pattern, with weakness, speech change, or vision loss in one eye.
- Fevers, pelvic pain, or a foul discharge if a coil is in place.
When this comes up in consultation I would rather see you once too often than have you sit on a clot or a heavy bleed because you did not want to make a fuss about hormones.
How do you review this at Clinique Alpa?
You are seen face to face at 466 Green Lanes, Palmers Green, or at home if leaving the house is the problem. A 30 minute GP appointment is £100. If the diary has a same day slot, you can take it, subject to availability. If it does not, you take the next one. We would rather show you a real time than invent one.
Bring the packets, the coil dates, any recent blood results, and a note of what still works and what has gone. If bloods are needed, the draw is £20 plus the specific test. A referral letter is £50 where it is clinically appropriate after assessment. None of that is done as a stamp on the way out.
Women’s health sits in the same building, with time to go through menstrual, hormonal and general concerns properly. Dr Morawala’s surgical eye is there if a coil or a bleed needs that lens. You will be told the fee before we start. Read the same day GP page if you need to be seen today, or the home visiting GP page if the house is the safer room.
If the nights have gone again, come in rather than stopping on the bathroom shelf. We look, we adjust if that is what the picture supports, and we say so if the next step is not us.
Book a face to face review rather than stopping on your own. Read our fees page, or call 020 8882 8088. Home visits £250 day, £450 night, published in full. In an emergency call 999. Subject to availability.
Written by Dr Mitesh Parmar, MBBS MRCGP, GP and founder of Clinique Alpa, 466 Green Lanes, Palmers Green, London N13 5PA. This article is general information, not personal medical advice. In an emergency call 999. For NHS advice call 111 or visit nhs.uk.