Editor’s Note: Understanding women’s reproductive physiology across the lifespan is central to fertility literacy education, including during the transition to menopause. In this article, Alexa Gingerich, DO, summarizes the FIGO position paper by Genazzani et al., which examines individualized counseling about the benefits and risks of menopausal hormone therapy. Dr. Gingerich wrote this review while participating in the FACTS elective as a medical student and is now an OB-GYN resident at ChristianaCare in Delaware. Her summary highlights the importance of hormonal literacy, shared decision-making, and patient-centered care in supporting women’s health beyond the reproductive years. To learn more about the perimenopausal transition, sample Part C of our CME.
Introduction
As women conclude their reproductive years and enter menopause, appropriate treatment of menopausal symptoms can both increase quality of life and disability-free years, as well as decrease mortality in certain individuals.[1] Counseling in menopausal women: How to address the benefits and risks of menopause hormone therapy. A FIGO position paper by Genazzani et al. provides an important overview of structuring a risk versus benefit conversation by discussing details on the systemic effects of menopausal symptoms and the risks and benefits of menopausal hormone therapy (MHT). This topic is important to address, as there is an identified need for increased menopause training in graduate medical education.[2]
Menopause marks a natural transition in a woman’s life, but it is often accompanied by symptoms that significantly impact physical, emotional, and social well-being. The cessation of ovarian hormone production has systemic consequences that extend far beyond vasomotor symptoms alone. The 2024 FIGO position reframes menopause from merely the end of reproductive function to an opportunity for preventive care that evaluates cardiovascular, skeletal, cognitive, and metabolic health. FIGO emphasizes that counseling should center on the patient’s experiences, comorbidities, and individual risk factors, while addressing misinformation surrounding hormone therapy. [1]
“Menopause marks a natural transition in a woman’s life, but it is often accompanied by symptoms that significantly impact physical, emotional, and social well-being.”
MHT remains the first-line therapy for moderate to severe vasomotor and genitourinary symptoms in women without contraindications. When appropriately prescribed, MHT not only improves quality of life but can also reduce the risk of long-term morbidity related to osteoporosis, cardiovascular disease, and metabolic dysfunction. However, decades of inconsistent public messaging have led to widespread fear regarding hormone therapy, particularly after the early reports from the Women’s Health Initiative. [3] FIGO aims to correct these misconceptions by contextualizing risks and reinforcing that benefits often outweigh harms when treatment is tailored and initiated within ten years of menopause—the so-called “window of opportunity.” [2]
“When appropriately prescribed, MHT not only improves quality of life but can also reduce the risk of long-term morbidity related to osteoporosis, cardiovascular disease, and metabolic dysfunction.”
Discussion
When initiated in appropriate candidates, MHT provides measurable benefits across multiple systems:
- Cognitive and Mood Effects: Early initiation of MHT—particularly within five years of the final menstrual period—can improve sleep quality, reduce depressive symptoms, and may protect against cognitive decline in women who undergo premature or surgical menopause. [2]
- Cardiovascular and Metabolic Health: Estrogen has vasodilatory and anti-atherogenic properties. FIGO and the American College of Obstetricians and Gynecologists (ACOG) both report reduced cardiovascular risk and overall mortality in women who begin MHT before age 60 or within 10 years of menopause onset. Transdermal estrogen combined with micronized progesterone or dydrogesterone is preferred because of its favorable thrombotic profile. [2, 4]
- Bone Health: MHT increases bone mineral density and decreases fracture risk, with benefits that persist for years after discontinuation. [2]
- Sexual and Genitourinary Function: Vaginal estrogen and prasterone (vaginal DHEA) effectively treat vulvovaginal atrophy and dyspareunia. Tibolone, a synthetic steroid with estrogenic and androgenic activity, improves libido and sexual satisfaction, while ospemifene provides a non-estrogen oral alternative. [2]Longevity: Women with premature ovarian insufficiency who initiate MHT before age 50 experience increased survival and improved quality of life. [2]
The primary contraindications for systemic MHT include a history of breast cancer, venous thromboembolism, stroke, active liver disease, or coronary heart disease. Importantly, the risk profile depends on formulation, route, and timing. Oral conjugated equine estrogen and older synthetic progestins (medroxyprogesterone acetate or norethisterone) carry higher risks of thromboembolism and breast cancer. In contrast, transdermal estradiol with natural progesterone or dydrogesterone offers a more favorable safety profile. As previously mentioned, the 5- to10-year window of initiation within the perimenopausal years is ideal to reduce associated risks. Annual re-evaluation is essential to reassess risks, monitor symptoms, and ensure ongoing benefit. [2]
“The primary contraindications for systemic MHT include a history of breast cancer, venous thromboembolism, stroke, active liver disease, or coronary heart disease. Importantly, the risk profile depends on formulation, route, and timing.”
The FIGO committee recommends only FDA-approved bioidentical formulations, such as 17-β-estradiol and micronized progesterone, because they have established safety and efficacy data. [2], [5] FIGO strongly discourages the use of compounded “bioidentical” hormones. These preparations lack regulatory oversight and may have variable potency and purity, increasing the risk of under- or overdosing and potential endometrial hyperplasia.
FIGO’s recommendations align closely with those of ACOG and the North American Menopause Society (NAMS). All endorse MHT as first-line therapy for symptomatic women, recommend initiation within the “window of opportunity,” and advocate for the lowest effective dose individualized to each patient. The FDA, however, takes a narrower stance and only approves MHT to treat moderate-to-severe vasomotor and atrophic symptoms rather than for prevention. FIGO expands on this by emphasizing MHT’s broader role in preventive health and global quality of life improvement. [2], [5], [6]
“FIGO … ACOG and the North American Menopause Society (NAMS) all endorse MHT as first-line therapy for symptomatic women (and) recommend initiation within the “window of opportunity.’”
From a fertility-awareness perspective, understanding menopause physiology complements education on natural family planning and the reproductive life cycle. The same hormonal literacy used to interpret fertile and infertile phases during reproductive years can empower women to understand their post-reproductive hormonal health. The FIGO paper reinforces that menopause care, like fertility education, should prioritize patient empowerment, shared decision-making, and evidence-based use of hormonal therapies.
Genazzani et al.’s FIGO position paper reframes menopause as a pivotal stage in preventive medicine rather than solely the conclusion of a woman’s reproductive years. By advocating for individualized counseling, early initiation of appropriately selected MHT and integration lifestyle interventions, FIGO promotes an evidence-based, patient-centered model of care. This approach aligns with fertility-awareness principles of hormonal literacy and informed choice. Embracing these recommendations can enhance women’s health, autonomy, and quality of life well beyond reproductive years.
REFERENCES
[1] Genazzani AR, Divakar H, Khadilkar SS, et al. Counseling in menopausal women: How to address the benefits and risks of menopause hormone therapy. A FIGO position paper. Int J Gynecol Obstet. 2024;164:516-530. doi:10.1002/ijgo.15278
[2] Allen JT, Laks S, Zahler-Miller C, et al. Needs assessment of menopause education in United States obstetrics and gynecology residency training programs. Menopause. 2023;30(10):1002-1005. doi:10.1097/GME.0000000000002234
[3] Writing Group for the Women’s Health Initiative Investigators. Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women’s Health Initiative Randomized Controlled Trial. JAMA. 2002;288(3):321–333. doi:10.1001/jama.288.3.321
[4] ACOG Practice Bulletin No. 141: Management of Menopausal Symptoms. Obstet Gynecol. 2014;123(1):202–216 (Reaffirmed 2023).
[5] U.S. Food and Drug Administration. Compounded “Bioidentical” Hormones Q&A. Updated 2022.
[6] “The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. doi:10.1097/GME.0000000000002028
ABOUT THE AUTHOR
Alexa Gingerich, DO, is an OB-GYN resident at ChristianaCare in Delaware. She earned her medical degree from Rowan-Virtua School of Osteopathic Medicine in Stratford, NJ, and completed her undergraduate education at Temple University in Philadelphia, PA. She is interested in menopausal gynecologic care that supports whole-person well-being. During medical school, she enrolled in the FACTS elective to gain a better understanding of the physiology of the female reproductive system at various life stages and ways to share these methods with future patients so they are more empowered over their health and reproductive decisions.
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