HRT & Nutrient Depletion: How your vitamin levels can be impacted by Hormone replacement therapy.

Written by Dr. Robin Andrews and reviewed by Dr. Harriet Connell

HRT is generally recognised as the gold standard treatment for managing difficult, often life-affecting, perimenopause and menopause symptoms. Typically these include hot flushes, sleep problems, mood changes, weight gain, brain fog, vaginal dryness, low libido and joint pain - and HRT is recommended by both The National Institute for Health and Care Excellence (NICE) and the British Menopause Society (BMS) as a first line of treatment to alleviate these side effects. In short, HRT helps to replace hormones – primarily oestrogen and progesterone and/or in some cases testosterone - that your body is no longer producing as you go through the perimenopause and menopause. Around 15% of women in the UK aged between 45 to 64 are currently prescribed HRT¹ and many describe it as having an overwhelmingly positive effect on their well-being and mood. Evidence also shows that as well as easing perimenopause and menopause symptoms, HRT can reduce the risk of osteoporosis (fragile, brittle bones) by increasing levels of oestrogen² and, for some women who start taking it early in their menopause, cardiovascular disease.³

Risks, side effects and why HRT causes nutrient depletion

As with any medication, side effects when using HRT are common and frequently include headaches, nausea, bloating, breast tenderness, muscle cramps and unexpected vaginal bleeding. In fact, around 33% of women report side effects,⁴ eight out of 10 abandon the medication completely within two to three years⁵ and 40 % give it up after just four months.⁶ It is also not uncommon for some women to say they feel worse after using HRT than before taking it. If troublesome symptoms do persist your HRT type, dosage or mode of delivery (ie. pill, patch, gel, spray or vaginal ring) can usually be changed and/or tweaked accordingly after a few months to help resolve any problems.⁷ 

One of the lesser known side effects, however, is the potential for HRT to deplete your body of essential vitamins and minerals. Many factors influence nutrient status including smoking, heavy drinking, chronic stress, illness, poor diet and many common medications, plus as we age we simply don’t absorb some vitamins and minerals as efficiently as we once did. Results from the 2018 National Diet and Nutrition Survey show women between the ages of 50-59 are not getting enough folic acid, calcium, magnesium, potassium, selenium, iodine and copper.⁸ Why this is significant is that women going through the menopause are already increasingly at risk of deficiencies due to the sharp fall in oestrogen at this transitional time and therefore have a greater requirement of certain nutrients to ‘offset’ these hormonal changes. Research also shows us that the hormones in HRT can potentially ‘steal’ some key nutrients needed for optimum health including vitamin C, folate (vitamin B9), vitamin B12, vitamin B6 and the minerals magnesium, selenium and zinc.⁹

How do the hormones in HRT deplete nutrients? As with taking hormonal contraceptives like the combined oral contraceptive (COC) pill, using HRT increases certain hormones, notably oestrogen and progesterone, in the body. This supplementation of exogenous hormones causes a number of physiological changes in the body including:

1. Accelerated metabolism of active nutrients. Evidence indicates that exogenous hormones like HRT and hormonal contraception accelerate the metabolic pathways that consume nutrients such as Vitamin C, leading to lower levels available for storage and use¹⁰ 

2. Impaired absorption through reduced capacity of transfer proteins. Vitamin B12, vital for DNA synthesis and energy metabolism, is likely depleted through mechanisms that involve reduced binding capacity of a protein essential for B12 absorption in the stomach ¹⁰,¹¹

3. Reductions in co-enzymes responsible for forming active nutrient compounds. Vitamin B6 levels are reduced due to the induction of enzymes like tryptophan oxygenase, leading to decreased availability of B610 

4. Excretion of key micronutrients. Exogenous oestrogens can lead to sodium retention and fluid accumulation. The increased sodium retention can disrupt the balance of electrolytes such as magnesium and zinc, as these minerals are often excreted at higher rates to compensate for sodium accumulation¹⁰

5. The loss of certain nutrients can trigger cascading effects on others. Nutrients such as magnesium are essential for over 300 enzymes to function properly¹⁰. Exogenous hormones like HRT can lower magnesium levels, potentially disrupting enzymatic processes, leading to deficiencies in other compounds. For example, vitamin B6 and magnesium are interdependent in several enzymatic reactions, meaning reductions in one can exacerbate deficiencies in the other.

It should also be pointed out that some of the symptoms of nutritional depletion which are linked to using HRT are also commonly reported side effects of the menopause so it can help to track and monitor your symptoms closely so you can discuss them with your GP or health provider who can help to unravel, and diagnose, the potential cause.

Nutrients known to be affected by HRT

These are the nutrients most at risk of depletion if you are using HRT and the effects that any potential shortfall could have on your general, hormonal and nutritional health:

Vitamin B12  - a nutrient found in red meat, fish, liver, eggs and dairy products which is essential for nerve health, energy production, bone health and cell repair, research shows levels of this nutrient become lower with age as your body loses its ability to absorb it as effectively¹² Vitamin B12 can also be depleted by drinking alcohol and long term use of some medicines (such as metformin, a common treatment for diabetes and some antidepressants13. As the most potent sources of B12 are from animal sources those following a vegetarian or vegan diet may also be at risk of low levels. Research suggests that an increased percentage of women going through the menopause who are low in vitamin B12 may be at risk of possible neurological symptoms due to vitamin B12 deficiency.¹⁴ These can include fatigue, muscle weakness, pins and needles, numbness, psychological problems including anxiety, depression, irritability and/or memory problems and confusion or ‘brain fog’ (symptoms which can mimic the early signs of dementia), loss of motivation and drive, incontinence and problems with balance and co-ordination.¹⁵ 

Folic acid or folate (vitamin B9) – found in leafy green vegetables like broccoli and cabbage, pulses such as chickpeas or lentils and grains such as quinoa and brown rice. An estimated nine-12% of older people in the UK are considered to be deficient in folate – with the most common cause being low dietary intake.¹⁶ Some people may not have any obvious signs of deficiency and may only be picked up only from a blood test but some common symptoms can include tiredness, feeling faint, becoming easily breathless and headaches, memory problems, heart palpitations, skin cracking at the corner of your mouth, insomnia, depression and anxiety.¹⁷ Various research from the 1980s onwards has suggested a link between low folic acid levels and a higher risk of cardiovascular disease. Folate appears to reduce the risk by lowering high blood pressure, improve blood flow and reducing levels of harmful LDL cholesterol.¹⁸ Folic acid is also known to reduce homocysteine (an amino acid) levels in the body and having elevated homocysteine may indicate you have a vitamin deficiency and also put you at higher risk of cardiovascular disease.¹⁹

Vitamin B6 – also known as Pyridoxine, is found in beef, tuna, salmon, poultry, chickpeas, cereals and vegetables. Requirements for vitamin B6 increase as we get older as we can have problems absorbing and digesting it effectively.²⁰ Depletion can then lead to increased anxiety, depression and sleep issues (all well-documented side effects of the menopause) and an increased risk of heart disease (a particular concern during the menopause due to declining levels of heart-protective oestrogen). Vitamin B6 also works synergistically with folate to help produce serotonin (the so-called ‘happy hormone’) and fluctuating levels of this neurotransmitter could be a contributory factor in the mood swings many women experience during the perimenopause and menopause.

Vitamin C – an antioxidant vitamin found in citrus fruits, peppers and dark green leafy vegetables. A deficiency of vitamin C is rare but levels of it do tend to be lower as we get older. Vitamin C is crucial for women during menopause as it plays a vital role in collagen production which helps to maintain healthy skin, joints (joint pain is a common complaint during perimenopause and menopause) and connective tissue all of which can deteriorate with the decline in oestrogen. Vitamin C is also important for helping the body to utilise the mineral iron (see below). Getting enough vitamin C is also linked to a reduced risk of the bone-thinning condition osteoporosis, hip fractures and lowered bone mineral density (the measure of calcium and other vital minerals in your bones).^21,22 Figures from 2024 from the National Institute for Health & Care Excellence (NICE) suggest up to 14,000 women in the UK are at risk of fractures following the menopause.²³

Magnesium – a mineral found in bananas; green leafy vegetables such as broccoli, cabbage and spinach; nuts and seeds; pulses, dark chocolate and seafood (particularly fatty fish like salmon and mackerel). This is a particularly important mineral for women going through the menopause – not least because you are at an increased risk of deficiency as you get older –which helps to support healthy bones, hormone levels, sleep quality and regulate mood. Around 60% of magnesium in the body is stored in your bones where it is essential in preventing osteoporosis and creating strong and healthy bones and research from 2023 shows one in three post-menopausal women may experience fractures due to low bone density.²⁴ Magnesium is also known to help synthesise and activate vitamin D²⁵ (post-menopausal women are predisposed to vitamin D deficiency due to their age, changes in body composition and the fact they don’t absorb it as easily)^26,27and a study has shown that improving levels of magnesium in post-menopausal women had a beneficial effect on their vitamin D status (vitamin D deficiency is also linked to an increase in menopausal vasomotor symptoms such as hot flushes and night sweats, vaginal atrophy and osteoporosis) .²⁸ Vitamin D also helps your body to absorb calcium, another go-to nutrient for strong healthy bones that is shown to become harder to absorb as you age²⁹ and even if you do get enough calcium from your diet, your body cannot absorb it effectively if you don’t get enough vitamin D. Magnesium is also known to play a role in the production of the mood-regulating hormone serotonin which may explain why this mineral appears to have a beneficial effect in easing anxiety and depression (side effects of the menopause frequently reported by women). Levels of magnesium can also be reduced by stress and high intensity exercise.

Zinc – a mineral found in shellfish (oysters are particularly high in zinc although few of us eat them on a regular basis); meat; pulses; nuts and seeds; eggs and wholegrains such as quinoa which plays an important role in hormone regulation, immunity and wound healing. It is also known to regulate the stress hormone cortisol and help manage mood changes, a side effect commonly reported during both perimenopause and menopause. Research has shown women who took a daily multivitamin containing zinc reported positive improvements in mood.³⁰ Zinc is also key for healthy bone formation, along with key minerals calcium and phosphorous and vitamin D. A study on healthy post-menopausal women has shown that after eight weeks of taking zinc the status of vitamin D in the body improved and that supplementing with zinc can help to maintain bone health during menopause. ³¹

Selenium - this is a mineral found in Brazil nuts; cereals, fish and shellfish; beef, pork and poultry which is important for immunity, thyroid function and also for helping antioxidants (substances which help to ‘mop up’ free radicals which can cause damage to cells and DNA). Low levels of selenium are already a growing problem in the UK  due to low levels of it in the soil and many women are getting below the recommended levels according to the 2018 National Diet and Nutrition Survey. Research has shown that postmenopausal women who had higher intakes of selenium were less likely to have osteoporosis.³² Eating just one to two medium-sized Brazil nuts daily should provide you with the recommended daily allowance.

Nutrients that can increase when taking hormonal contraception

As is the case with oral hormonal contraceptives there are also some nutrients that have been shown to increase this is also true when taking hormone replacement therapy. It is not recommended that you take supplements (either singly or as part of a multi vitamin and mineral) containing copper. Concentrations of this trace mineral (found in shellfish, offal, nuts, seeds and wholegrains) have been shown to be higher in women using HRT suggesting that hormone supplementation provides beneficial effects on the status of this particular trace mineral.³³

Getting, and maintaining, the nutrients you need

Many of the potential nutritional depletions linked to using HRT can be prevented, reduced or managed by general healthy lifestyle measures including not drinking too much alcohol, not smoking, getting enough sleep, cultivating a thriving gut microbiome, managing stress, taking regular exercise and obviously having a varied and balanced diet. Ensuring you are getting a good level of vitamins and minerals from your food (a Mediterranean-inspired diet should provide you with pretty much what you need) is key. With the best will in the world, however, sometimes we don’t absorb everything we need from diet alone and taking a multivitamin and mineral – specifically one designed for women taking HRT that takes into account how hormone replacement may lead to potential depletions - can fill any small, but sometimes critical, gaps in nutrition.  In short, taking a supplement acts as a convenient and effective ‘insurance policy’ to ensure you get what you need nutritionally when using HRT and when you might not be getting everything you need from food alone.

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