FIGO and IMS: Treat Early Menopause as a Chronic Condition

On 18 August 2026, the International Federation of Gynecology and Obstetrics (FIGO) and the International Menopause Society (IMS) published a joint position paper in the journal Climacteric. Its central claim is that when a woman's ovaries stop working early, that is not an early version of ordinary menopause. It is a chronic endocrine condition, and the paper argues it should be treated like one: hormone therapy started promptly, dosed at replacement levels, and continued long term.

This is the first time the two organizations have set out a shared position on this group of women. The paper is a consensus statement, not new trial data, so what matters is the evidence underneath it and what it does not establish.

Who this is about

The 2024 evidence-based guideline on premature ovarian insufficiency, written jointly by ESHRE, ASRM, CRE-WHiRL and IMS, defines premature ovarian insufficiency (POI) as loss of ovarian activity before age 40. It uses the term early menopause for ovarian function ending between 40 and 44.

What separates this from menopause at the usual age is duration. A woman who reaches menopause at 51 and a woman who reaches it at 33 lose the same hormone. The second one lives without it for roughly eighteen additional years. The FIGO and IMS paper argues that this longer exposure is why POI and early menopause are associated not only with a shorter lifespan but with a shorter healthspan, through higher risks of cardiovascular, skeletal, cognitive and psychological problems along with sexual health concerns. Related research also ties long-term hormone therapy use to functional outcomes like grip strength across the lifespan, one more thread in that healthspan picture.

What the paper asks to change

Three things: timely initiation, adequate dosing, and long-term continuation. The authors describe current care as "fragmented, delayed, and overly influenced by paradigms derived from older postmenopausal populations."

That last phrase is the whole argument in miniature. Much of the caution around hormone therapy traces back to trials run in women in their sixties who had already reached menopause at the usual age. FIGO and IMS argue that carrying that frame over to a 32-year-old with POI misreads her situation, because she is not being given hormone above what her body would otherwise produce. She is being brought back toward what her peers still have.

The 2024 four-society guideline states this as a strong recommendation: hormone therapy for women with POI until the usual age of menopause, for primary prevention of illness and death, whether or not symptoms of estrogen deficiency are present. It also names a minimum daily estradiol dose intended to protect bone, higher than the doses typically used for menopause at the usual age. What that means in practice is a decision for a prescribing clinician, not something to work out from an article.

What the evidence shows

Bone

A 2023 systematic review in Maturitas by Costa and colleagues screened 335 articles and analyzed 16 studies of women with spontaneous POI who had bone density measured. Most of those studies found lower bone density at the femoral neck and lumbar spine in women with POI than in healthy women. Bone mass tended to stay stable in women treated with estrogen plus progestin. Two findings are worth sitting with: in women who had already lost bone mass, therapy at the doses most frequently used did not reverse that loss, and interrupting hormone therapy for longer than one year was linked to significant bone loss. Dose and continuity, in other words, are where the bone benefit appears to live.

Symptoms and quality of life

A 2022 systematic review and meta-analysis in Reproductive BioMedicine Online by Gonçalves and colleagues pooled 30 reports of 28 studies covering 4,004 women who had POI from varied causes. Of those women, 3,785 received hormone therapy and 219 received calcium, vitamin D, placebo or no treatment. Compared with those comparators, hormone therapy preserved bone mineral density better, was associated with up to an 80% reduction in the prevalence of hot flushes among the women studied, and was associated with quality-of-life scores that stayed stable or improved, a pattern consistent with a separate synthesis of 51 trials on hormone therapy's effect on mood, anxiety and sleep in women at the usual age of menopause. The review also found significant increases in uterine volume and endometrial thickness. Its authors graded the overall evidence moderate to high.

Both are systematic reviews pooling studies of differing lengths, so neither reports a single uniform follow-up period.

Where the evidence is thin

A strong recommendation is not the same thing as strong evidence, and this is a case where the two come apart.

• The four-society guideline's recommendation is graded strong, but the certainty of the evidence behind it is graded very low, and its dosing recommendation is conditional and also very low certainty. That combination reflects a judgment about the consequences of leaving a young woman without estrogen for decades, not a settled base of trials.
• In the Gonçalves meta-analysis, only 219 of 4,004 participants sat in a no-treatment, placebo or supplement comparison group. Some included studies lacked blinding or had incomplete outcome data.
• Neither review demonstrated fewer fractures or fewer cardiovascular events. Those are the outcomes that matter most, and the Gonçalves authors said plainly that more studies are needed on long-term safety and on hard outcomes such as bone fractures and cardiovascular events.
• Hormone therapy is not an option for everyone. The 2024 guideline lists prior breast cancer as a contraindication, and the FIGO and IMS paper devotes a section to managing POI and early menopause when systemic hormone therapy cannot be used. On breast cancer risk more broadly, the guideline says women with POI can be informed there is no evidence that hormone therapy raises their risk compared with women of the same age who do not have POI. No evidence of an increase is not the same as proof that there is none.

What this means if this is you

If your periods stopped before 45, this paper puts two questions on the table. Was the diagnosis actually made and confirmed at the time, or did it get filed as stress or as an unexplained gap? And if you are on something now, is it at replacement levels, or at the lower doses aimed at symptom relief in women who reach menopause at the usual age? Both are questions for a clinician who can see your labs and your history.

The other thing worth carrying out of the Maturitas review is that gaps matter. Bone loss tracked with interruptions longer than a year, and loss that had already happened was not reversed at the doses most commonly used. If your treatment history has been on and off, that is worth raising directly rather than leaving it to be inferred from a chart.