Understanding past climatic changes allows us to better understand how our planet will evolve in the future. One important source of information on paleoclimate is the analysis of speleothems that develop in karst caves and conduits due to the dissolution and precipitation of calcite. However, there are many uncertainties in paleoclimatic reconstruction with speleothems; one of them being hydrological variability. Up to now only few studies have considered the impact of hydrological variability on speleothem formation and composition. This review paper will provide an introduction to hydrological processes that have the potential to affect speleothem composition and the hydrological modelling approaches that are able to account for them. It presents the current state of knowledge on paleoclimatic reconstruction using speleothems and shows that many important flow and transport processes have not yet been included in the interpretation of these archives, mostly due to a lack of field information to parametrize them. Possible directions of future research efforts therefore include a better exploration of karst vadose zone processes and new approaches to incorporate this information into simulation models. Finally, we foresee the exciting advances in reconstructing paleohydrology using karst hydrology models combined with speleothem growth rate and geochemical composition to understand how past climate changes affected the hydrological cycle and water availability.