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.

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.