What did @elevatemd actually say?
The creator ranked eight hormone therapy delivery methods from best to worst for perimenopause and menopause symptom management. Injections and vaginal estrogen/DHEA tied for first. Oral progesterone came in second. Patches landed third. Suppositories and troches shared fourth and fifth. Transdermal creams, gels, and sprays ranked seventh. Oral estrogen landed dead last, eighth place, with the creator saying simply "last place" before moving on.
The ranking framework is largely delivery-route-based, centering on how well each method achieves stable hormone levels and avoids first-pass liver metabolism. That is a legitimate clinical lens. But ranking is inherently reductive, and several placements here deserve scrutiny.
Does the science back this up?
Partially. The creator's instinct to penalize oral estrogen makes pharmacological sense, but the nuance gets flattened. The case against transdermal creams being ranked below troches is shakier than the video implies.
The concern about oral estrogen centers on first-pass hepatic metabolism, which increases sex hormone-binding globulin (SHBG), triglycerides, and clotting factor synthesis. The ESTHER study (Canonico et al., 2007, Circulation) found that oral estrogen, but not transdermal estrogen, was associated with increased venous thromboembolism risk. That finding has been replicated and is clinically meaningful. Ranking oral estrogen last on safety-adjacent grounds is defensible.
Injections achieving the top spot is more complicated. Estradiol cypionate or valerate injections do produce high peak levels followed by troughs, which can actually worsen symptom consistency for some patients. The creator doesn't acknowledge this trade-off at all.
What did they get wrong (or right)?
They got the oral estrogen caution right. The hepatic metabolism concern is well-documented and the ESTHER data is solid. Giving oral progesterone second place also has support. Micronized progesterone (Prometrium) has a favorable cardiovascular and breast safety profile compared to synthetic progestins, as shown in the E3N cohort study (Fournier et al., 2008, Breast Cancer Research and Treatment).
Where the ranking gets sloppy: troches ranked above transdermal creams. Troches involve buccal or sublingual absorption but are often swallowed partially, meaning inconsistent delivery and variable serum levels. A 2019 review in Menopause (Stanczyk et al.) flagged compounded troches specifically for unpredictable pharmacokinetics. Meanwhile, FDA-approved transdermal estradiol gels and sprays have well-characterized absorption profiles. Ranking troches higher than approved transdermal products because they "bypass the liver" oversimplifies things considerably.
The creator also never distinguishes between compounded and FDA-approved versions of any of these forms, which matters enormously for safety and efficacy comparisons.
What should you actually know?
No single delivery method wins universally. Patient-specific factors, including skin sensitivity, needle tolerance, GI issues, and hormone levels at baseline, shape which option works best for any individual. The ranking format makes for good content but mediocre clinical guidance.
Vaginal estrogen and vaginal DHEA (prasterone) at number one for genitourinary symptoms is well-supported. Systemic absorption is minimal, and the 2023 Menopause Society guidelines endorse vaginal estrogen as first-line for genitourinary syndrome of menopause. That placement holds up.
On injections: estradiol injections are not FDA-approved for menopause management in women in the United States. They are used off-label. The supraphysiologic peaks followed by troughs can create symptom cycling that some patients find worse than patches or gels. Calling injections "number one, duh" without that caveat is not responsible clinical communication, even in a TikTok format.
If you are working through menopause symptoms, the right delivery method depends on your personal health history, your clotting risk, your lifestyle, and your provider's clinical judgment. A ranking video is a starting point for curiosity, not a treatment plan.