Nurse practitioner, clinic owner, and founder of HRT University. I teach providers the physiology behind hormone therapy, so they’re not piecing it together on their own.
Was I wrong about PO E2 clots?
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The Danes are up to something. The just put out a real rager of a study. And if you skimmed over it or just read the highlights, you would likely leave with one clear takeaway... Oral estrogen/estradiol causes clots. Womp womp. Except, that's not really the whole truth. To the best of our ability, we HAVE to weed out bioidentical from non-bioidentical hormones. See, estradiol and estrogen are not the same at all. Neither is progesterone vs progestins. Both significantly contribute to overall clot risk - more so than the bioidenticals. In fact, in the RCTs, we have not seen oral estradiol (E2) and oral progesterone (P4) increase the risk of clots. At all. And that's a very important signal to remember. Because unfortunately, the vast majority of studies looking at HRT aren't looking at the bioidenticals. They're looking at the non-identical hormones that carry greater risk of clots. If we stratify these risks, it starts looking confusing. And that's because you have to take these studies with a huge grain of salt. So, I took the liberty of stratifying the HRT regimen and risk for you to help you better understand. See below:
HRT clot counts are estimates: each ratio applied to a baseline of about 10 per 10,000 for women in their 50s. Compare the clot counts across sections, not the ratios, because the two groups start from different baselines. First of all, women carry risk of clot without HRT. And they triple their risk taking oral birth control. And they 10-30x their risk between pregnancy and post-partum. So yeah, there's a lot of clotting-related risks in life. But when it comes to HRT, the risks are actually minimal when considering the overall benefits. And when it comes to Oral E2, I want to be clear. It has never been shown to increase the risk of clots in RCTs. And what data shows an increased risk of clots is in observational studies only. And it moves from 1.0 to 1.4... It's a signal, but we have to take into account that it's not randomized or controlled for. Nor does it consider the benefits of concurrent P4 either. So we can't just throw the baby out with the bathwater. There's a HUGE shortage of these patches and topicals out there right now. And so women are left to suffer again... but for no good reason. Oral E2 is a great solution, and the more you understand it and its benefits, and create a shared-decision and informed consent with your patients, the less you have to be scared and worried over it. That's the power of breaking this type of information down. And I have a whole podcast episode you can check out if you want to learn more of the ins and outs on this subject :) Hope this helps, -Nico PS If you love learning about this stuff, I highly recommend checking out the HRTU Master Course to help you feel more confident in HRT.  References: https://www.bmj.com/content/bmj/394/bmj-2026-100688.full.pdf | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
HRT University
Nurse practitioner, clinic owner, and founder of HRT University. I teach providers the physiology behind hormone therapy, so they’re not piecing it together on their own.
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