How viral menopause content oversimplifies HRT risks — and what current evidence actually suggests

Claim 2: “side effects include…clots increasing your risk for a stroke”

Fact check: Partly true/ Misleading

The absolute risk of clot or stroke is very small when treatment commences before the age of 60, within 10 years of menopause, using a low dose, transdermal estrogen alongside micronised progesterone and in otherwise healthy women (source, source). 

A 2019 UK observational study found that the risk of blood clots with HRT varies by formulation and route of administration. Oral HRT was associated with an increased risk of venous thromboembolism (VTE), particularly preparations containing conjugated equine estrogen, such as those used during the WHI study, and higher estrogen doses. In contrast, transdermal HRT (such as patches or gels) and tibolone were not associated with an increased clot risk. The findings suggest that VTE risk is influenced more by how HRT is delivered and the type of estrogen used than by HRT as a single category.

HRT is linked to a small increase in stroke risk while women are taking it, but this risk disappears once treatment stops (source). The increase is modest, a higher relative risk compared to people who do not use HRT, but for most healthy women, especially those under the age of 60, it translates to only a small absolute increase: roughly a few extra strokes per 10,000 women per year of use (source). 

While clots and stroke are potential serious side effects, they’re not universal side effects of HRT and risk changes based on regimen, route, age, and baseline health status. Presenting them as inevitable and large is misleading. HRT is associated with a small increase in the relative risk of stroke and venous blood clots compared with people who do not use HRT. 

What we do know:

• Oral estrogen* increases the risk of blood clots (venous thromboembolism, or VTE) and, to a lesser extent, strokes, particularly in older women and those with other risk factors, such as thrombophilic conditions (source, source, source, source)
• Transdermal estrogen, such as a patch, gel or spray at standard doses, has little to no detectable increase in VTE risk in many observational studies (source)
• The absolute risk remains low in healthy women under 60 years of age

Many of the claims related to the risks of HRT can be traced back to the influential Women’s Health Initiative (WHI) study published in 2002 (source). The well-known WHI study focused on an older postmenopausal population (average age 63), who are not representative of the majority of women who do HRT today. The women in this study either took an oral combined conjugated equine estrogen (CEE), a type now rarely used, or a synthetic progestin (source). 

*As oral estrogen treatments, such as those used in the WHI study, must bypass the liver, this has a significantly different physiological impact than the creams, patches, pessaries and gels used nowadays - many of which are bioidentical (source). 

What the research shows:

• Timing: HRT is safest and most effective when started during perimenopause or within 10 years of a woman’s final period. Research shows that HRT use among women age 60+ carries an increased risk (source)
• Form and combination: HRT is not a single uniform treatment and may involve estrogen, progestogen, testosterone, Tibolone or DHEA. Risk then depends on the combination of hormones and how they are taken. For example, an estrogen-only treatment taken orally increases the risk of a blood clot (source). However, estrogen-only treatment taken transdermally is considered low risk in appropriate candidates. Oral micronised progesterone is generally considered to have a favourable safety profile (source). When estrogen and progestogen are combined, the risk varies by progestogen type (source). Topical vaginal hormone treatments are absorbed locally rather than systemically - throughout the whole body - and have not been shown to increase the risks of venous thromboembolism, stroke or breast cancer (source, source).
• Dose: ideally lowest dose for the shortest amount of time 

To sum up

Some risks exist, but they depend heavily on:

• Age at starting HRT
• Time since menopause
• Type and combination of hormone(s) (estrogen alone vs estrogen + progestogen)
• Route (oral vs transdermal patch/gel/pessary)
• Dose and duration
• Health status of individual

Bottom line: The best recent evidence paints a nuanced picture: for the right woman, started at the right time, modern HRT has small absolute risks and often substantial benefits. In healthy women using hormone therapy during perimenopause, starting before the age of 60, or within about 10 years of their final period, guidelines conclude that symptom relief and bone protection generally outweigh the small, treatment‑dependent increases in breast cancer, clotting, and stroke risk, particularly when transdermal estrogen is used.

What do we know about the role of vitamin D supplementation in Menopause?

Vitamin D deficiency is quite common, and supplementation can be effective for people of all genders and ages, especially during the wintertime (source). It is a particularly important nutrient for women in perimenopause and menopause, as it supports bone health, which is impacted by hormonal changes during this time (source). Declining estrogen levels can result in bone loss and lead to a greater risk of developing osteoporosis, especially when women have a sedentary lifestyle and/or do not pay attention to their diet. In addition, Vitamin D also helps regulate the immune system. This is because many immune cells have special receptors for vitamin D on their surface. These receptors are also found in different parts of the body, including the kidneys, gut, breast, prostate, and brain (source).  

Claim 3: “Vitamin D3, I would highly recommend you do 20,000 IUs”

Fact-check: This claim is misleading. While Vitamin D3 supplementation can be beneficial for preventing or treating deficiencies, there is no evidence to support the claim that taking daily megadoses of 20,000 IUs is safe or effective. 

What we know:

• Vitamin D is important for bone health, and guidelines recommend ensuring adequate vitamin D and calcium intake to reduce the risk of osteoporosis (source)
• Current clinical guidelines recommend daily doses for at-risk populations ranging from 800 to 2000 IU (International Units), adjusted according to individual needs, sun exposure, diet and the individual's biochemical response. It is recommended to opt for lower doses (800-1000 IU daily), which are considered safer (source) 
• The tolerable upper intake level (UL) for adults is 4,000 IU (100 micrograms) per day (source)
• No major menopause association singles out vitamin D as “the most important” therapy or supplement for menopausal symptoms in their official guidance (source) 

“More is not always better: it has been observed that vitamin D levels have a U shape effect (source). Deficiency and excess can both be detrimental for bone health.

Bottom line: This is not evidence‑based. Adequate vitamin D is important for bone and general health, but it is not the primary or most important intervention for menopausal symptoms based on current evidence or guidelines. If you consider that the general recommended daily dose ranges from 600 to 1,000 IUs, with a maximum safe upper limit of 4,000 IUs, a blanket recommendation of 20,000 IUs per day is irresponsible. More importantly, supplementation should always be carried out under the guidance of a medical practitioner and informed by a blood test, to first establish if a deficiency is present. 

Let’s talk about risk

Risks posed by any medical treatment should be clear and understood by a patient before commencing therapy. What’s also important is weighing those risks against the potential benefits to understand where the balance lies. 

How big are the risks from HRT? Absolute vs relative risk

We come across the term ‘risk’ fairly often in relation to HRT. There are different ways of thinking about risk, namely, absolute and relative risk.

To clarify, absolute risk is the literal, concrete probability that an event will occur in a defined group and can be expressed as a percentage or as a fraction of chance, e.g., 1% or 1 in 100 people. So if 10 out of 100 people develop a disease, the absolute risk is 10%. Where things can be less clear is when we talk about relative risk. 

‍Relative risk tells us how much something increases (or decreases) risk compared to a baseline. If a treatment increases risk by 50%, that can sound alarming. But 50% of what? If the baseline risk is 2 in 1,000, a 50% increase raises it to 3 in 1,000. The relative increase sounds significant, while the reality is that the absolute increase is 1 extra case per 1,000 people.

This distinction, between absolute and relative risk, is important when we’re considering medical treatments such as HRT. While some real risks are present, when you consider them in absolute terms and weigh them against the potential benefits, the decision-making process can become clearer, or at least less fraught. 

For most healthy women in their 40s and 50s, the baseline risk of serious events like blood clots or stroke is already low. Certain types of HRT, particularly oral formulations, may slightly increase that risk. But we are usually talking about small absolute increases. For example, a risk that might rise from around 2 per 1,000 women over several years to 3 or 4 per 1,000. That is an increase, and should be taken seriously, but it is not the same as a high likelihood of harm.

Breast cancer risk can be an area of significant concern. Context matters here as well. The risk varies depending on the type of HRT, the duration, and the individual's health status. For five years of use starting at age 50 (source):

• Continuous combined therapy leads to about 1 extra case per 50 users.
• Intermittent combined therapy: about 1 extra case per 70 users.
• Estrogen-only therapy: about 1 extra case per 200 users.
• Longer use increases risk further — ten years roughly doubles the additional cases. 

The level of risk depends strongly on the formulation, which is often overlooked in simplified headlines.

An increase in risk is present. But it is small in absolute terms, and it accumulates over many years rather than representing an immediate or dramatic shift in risk. Risk also declines after stopping HRT.

Modern prescribing practices, using lower doses and transdermal estrogen, are associated with a lower risk of clots than older oral regimens studied in trials such as the Women's Health Initiative, where much of the early fear originated.

This is not to dismiss risk but rather to place it in proportion. A relative risk headline can sound frightening; however, absolute risk tells us what that actually translates to in real life.

Social media, sensationalist claims, and misleading information

Yet again, we have another classic example of an unqualified influencer sharing cherry-picked information, using emotive, fear-mongering language and making ill-informed claims to grab attention, likes, shares and virality. The reality is:

• Blanket warnings regarding our health are rarely black and white (with some exceptions where the evidence is robust and well-documented, such as advice about the risks of smoking, for example)
• How we react to treatments is very individualised, so implying something is dangerous for all women is simply not realistic or accurate 
• It is important to remember that these conversations require far, far more context, including consideration of age, health status, dose and duration. A 1-minute reel will never be sufficient to provide an accurate and nuanced picture

How can we identify a misleading post?

1. Is this influencer qualified to advise on women’s health and menopause? What are their credentials?
2. Are their claims in line with the official guidance given by the major international menopause societies, e.g. BMS, ​The Menopause Society, EMAS?
3. Does the influencer have an additional agenda, i.e. are they trying to sell a regimen, protocol, product or something else?

Bottom Line

HRT, or MHT, can be a very effective therapy and a game-changer for women impacted by the many symptoms of peri- and post-menopause. Following the controversial 2002 WHI study and the confusion and fear that resulted from it, the number of women availing of HRT plummeted, and many suffered unnecessarily as a result. In the following decades, a clearer picture has emerged, allowing risks to be assessed and identified more effectively through individualised protocols based on age, health status, health history, onset of menopause and more. Updates and improvements to the types of therapy, the dose, the form and combination of hormones also mean that treatment can be effective and safe for many women. Risks do exist, and more so in some demographics, but blanket statements about the significant dangers of HRT for all women are simply not accurate and are unhelpful when women are looking for much-needed solutions. What is clear is that it can be a safe and effective therapy for many patients who meet the right criteria.

Take‑home for readers

• HRT decisions should be individualised (age, time since menopause, underlying health profile, risks, symptom burden)
• Vitamin D: test, use preventatively or to correct deficiency in line with guideline‑level doses, avoid megadoses without medical supervision
• Consult a qualified menopause specialist / GP, not social media, for specific treatment and dosing decisions 

We have contacted Dr. Berg and are awaiting a response.

Disclaimer

This fact-check is intended to provide information based on available scientific evidence. It should not be considered as medical advice. For personalised health guidance, consult with a qualified healthcare professional.