BHRT and other medications: what you need to know if you are taking multiple treatments

Many women in menopause use other medications alongside BHRT, such as antidepressants, blood pressure medication, thyroid medication, acid reflux inhibitors, or statins. A logical question is: do these work well together? And do I need to make any adjustments?

The good news is that most medications can be safely combined with BHRT. However, there are some points worth noting—and discussing with your doctor.

Thyroid medication (levothyroxine)

This is the most relevant combination. Estrogen—both endogenous and via BHRT—increases the production of thyroxine-binding globulin (TBG) in the liver. TBG binds thyroid hormone in the blood, leaving less free, active hormone available for the cells.

For women taking levothyroxine who start BHRT, the need for thyroid medication may increase. This is not a dangerous interaction, but it does mean that thyroid levels (TSH, free T4) should be monitored more closely after starting BHRT. At Menovia, we routinely measure thyroid levels for every patient.

Practical advice: Inform your doctor about your use of levothyroxine when starting BHRT. Schedule a thyroid check-up 6–8 weeks after starting.

Antidepressants (SSRIs and SNRIs)

SSRIs and SNRIs are sometimes prescribed for menopausal mood symptoms, even in the absence of clinical depression. They have some effect on hot flashes, but are less effective than BHRT for the full range of symptoms.

The combination of antidepressants and BHRT is generally safe. There is no significant pharmacological interaction that causes problems. Some women find that once they are well-adjusted on BHRT, they need fewer antidepressants because the hormonal root cause of their mood symptoms has been addressed. This is not a reason to stop taking antidepressants on your own—always do so in consultation with your prescribing physician.

Exception: tamoxifen. Some SSRIs (particularly paroxetine and fluoxetine) inhibit the CYP2D6 enzyme, which converts tamoxifen into its active form (endoxifen). Women using tamoxifen for breast cancer treatment must discuss this with their oncologist before starting SSRIs.

Blood pressure medication

BHRT can affect blood pressure—in either direction, depending on the type and method of administration. Transdermal estradiol has a more favorable effect on blood pressure than oral estrogens.

For some women, blood pressure improves after starting BHRT (due to reduced cortisol stress, better sleep, and the relaxation of blood vessels by estrogen). For others, blood pressure remains unchanged. Periodic monitoring is standard at Menovia.

Practical advice: Have your blood pressure checked when starting BHRT and periodically thereafter. If blood pressure medication remains necessary, that is perfectly fine—the combination is safe.

Statins (cholesterol-lowering medication)

Statins and BHRT work complementarily. Estrogen itself has a beneficial effect on the cholesterol profile (increasing HDL, lowering LDL). Women who started statins after menopause due to a worsening cholesterol profile may see their levels improve after starting BHRT, which may be a reason to evaluate their statin dosage.

There are no direct pharmacological interactions between statins and BHRT. Regular monitoring of the lipid profile is recommended.

Acid reducers (PPIs: proton pump inhibitors)

PPIs (such as omeprazole or pantoprazole) are relevant to BHRT for an indirect reason: stomach acid is necessary for the absorption of certain nutrients, including vitamin B12, magnesium, and calcium. Chronic PPI use can lead to deficiencies in these substances—all of which are relevant to hormonal health.

There are no direct interactions between PPIs and transdermal BHRT. However, with long-term PPI use, it is advisable to have B12, magnesium, and calcium levels checked.

Blood thinners (anticoagulants)

For women taking blood thinners (such as acenocoumarol, phenprocoumon, or direct oral anticoagulants like rivaroxaban or apixaban), extra caution is required with BHRT. Estrogen—particularly oral—affects clotting proteins. With transdermal administration, this effect is minimal, but it still warrants attention.

Women using blood thinners must always disclose this when starting BHRT. The physician will determine if and how BHRT can be safely initiated; in most cases, transdermal administration is possible, but it requires careful monitoring.

Epilepsy medication and CYP inducers

Some anti-epileptic drugs (such as carbamazepine, phenytoin, and rifampicin) are strong inducers of the CYP3A4 enzyme, which breaks down hormones in the liver. They can reduce the effect of BHRT through faster hormone metabolism. With transdermal administration, this effect is less than with oral hormones, but it does require more precise monitoring of blood levels and potential dosage adjustments.

Can you combine supplements with hormone therapy?

In most cases, you can use common supplements alongside hormone therapy without issue, but not every supplement is neutral. Vitamin D, magnesium, omega-3, and calcium generally combine well with BHRT and can support your bones, muscles, and overall lifestyle. Still, some supplements can affect how your medication works, are better taken at a different time, or are worth discussing with your doctor first.

St. John's wort is the best-known example. It is a strong inducer of liver enzymes (including CYP3A4) and can therefore reduce the effect of various medicines, hormones included. If you use St. John's wort for low mood, always discuss this with your doctor first.

High doses of phytoestrogens (such as concentrated soy isoflavones or red clover) have a weak estrogen-like effect. Alongside hormone therapy their added value is unclear, and little is known about combined use in high doses. Discuss this with your doctor, especially if you have an increased risk of hormone-sensitive conditions.

Omega-3 (fish oil) and vitamin E can have a mild blood-thinning effect in high doses. If you take blood thinners, mention your supplements too, so your doctor can weigh whether extra monitoring is needed.

Practical advice: at your intake, list not only your medication but also every supplement, vitamin, and herbal preparation you use. That way your doctor can assess whether something is better taken at a different time or needs extra attention. Keep in mind that supplements are an addition to your treatment and to a healthy lifestyle, not a replacement for a medical plan. They can contribute to your overall health, while the core of the treatment remains the carefully tailored hormone therapy.

What to do: open communication

The golden rule for any combination of medication and BHRT: be completely open about all medications you are taking when starting the process. No side effect or interaction is more painful than one that could have been foreseen.

At Menovia a complete medication list is part of the intake. We assess on a case-by-case basis whether adjustments are necessary and what monitoring should look like. More about how the process works.

Frequently asked questions

Can I simply keep taking vitamin D and magnesium alongside my hormone therapy? For most women this is not a problem. Vitamin D, magnesium, calcium, and omega-3 generally combine well with BHRT. Do mention them to your doctor, because the dose and timing can sometimes matter, and with blood thinners or St. John's wort extra coordination is needed.

This information is intended as an educational resource and does not replace medical advice, diagnosis, or treatment. If you have symptoms or questions about your personal situation, we recommend consulting a doctor.