Menstrual Changes
Menstrual changes may or may not be directly related to HIV disease. Any changes related to your menstrual periods should be thoroughly checked out by a health care provider and, if necessary, by a gynecologist. Once the source of the problem is identified, it can be treated appropriately. Even if there is no clear cause, there are many treatments to relieve symptoms associated with menstrual irregularities.
Some menstrual changes are normal, such as changes experienced because of pregnancy, menopause or perimenopause. Menopause is a stage in life when periods stop permanently, and a person is no longer able to become pregnant. Perimenopause is the stage before menopause, when changes occur in reproductive hormones and the body prepares for menopause.
But sometimes, menstrual changes are unexpected and may indicate a health problem. Periods may become irregular, occurring either more or less frequently than usual, and are sometimes missed entirely. Or the menstrual flow changes, with either heavier or lighter bleeding during some periods. The amount of bleeding may not be consistent from one period to another.
Some people who are not pregnant (or going through perimenopause or menopause) may have no period for a number of months, a condition known as amenorrhea. Others find that their premenstrual symptoms (PMS) become more difficult than they were previously.
While many cis women and trans men who are not on testosterone therapy, bleed during their periods, some trans women on gender-affirming hormone therapy experience a “bloodless period” characterized by regular monthly abdominal pain, cramping and other symptoms.
What is the impact of HIV?
HIV may have less impact on menstruation than originally thought. Studies report no significant differences between HIV-positive and HIV-negative cis women in excessive menstrual pain (also called dysmenorrhea), the development of perimenopausal symptoms or the development of early menopause. However, there may be an increased likelihood of missed periods (amenorrhea) and delayed periods (oligomenorrhea) in people with advanced HIV who are not on antiretroviral therapy.
Figuring out the cause
Reporting any menstrual changes to your healthcare provider is very important since these changes can indicate health problems related to the reproductive organs, including cervical dysplasia (early changes in cervical cells that can lead to cervical cancer), pelvic inflammatory disease or endometrial conditions.
Of course, menstrual changes can also indicate pregnancy. During pregnancy, unexpected bleeding could indicate miscarriage.
Menstrual irregularities can occur as a result of various sexually transmitted infections or almost any serious infection, HIV-related or otherwise. Some people living with HIV develop low levels of platelets (thrombocytopenia), which can contribute to heavier than normal menstrual bleeding.
Many other health issues can contribute to menstrual irregularities, including stress, eating disorders, hormones (not only changes in estrogen and progesterone but also in thyroid, pituitary and adrenal hormones, as well as testosterone therapy for some trans men), excessive weight loss, excessive exercise or the presence of other chronic diseases, including diabetes, kidney or liver disease and inflammatory bowel disease.
Many medications can cause menstrual changes, including various anticoagulants (blood thinners), narcotic pain medications, methadone, heroin, corticosteroids and others.
Some of the early protease inhibitors (such as high-dose ritonavir (Norvir), saquinavir (Invirase) and indinavir (Crixivan)) have also been associated with increased menstrual bleeding, Protease inhibitors used today – atazanavir (Reyataz), darunavir (Prezista and in Prexcobix) and low-dose ritonavir (Norvir) — are not associated with this problem. Because Aspirin can thin the blood, making it less likely to clot, long-term use of high doses of Aspirin can contribute to longer, heavier periods. Some herbal supplements can copy or mimic the effects of estrogen and taking these can also result in menstrual irregularities.
There is a higher risk of magnesium deficiency in people living with HIV. Magnesium deficiency can cause many problems, including a worsening of several premenstrual symptoms. In turn, some menstrual problems can worsen other HIV-related conditions. For example, people living with HIV have a high incidence of anemia (low red blood cells), and the risk is higher during menstruation because of the loss of blood. Since there is already an increased risk for anemia for people living with HIV, heavy bleeding should be discussed with your healthcare provider as it can worsen anemia.
Treatment for menstrual irregularities will depend on the problem and its cause. For people living with HIV who are not yet on antiretroviral therapy, beginning treatment is very important to raise CD4 counts. Lower CD4 counts have been associated with a higher risk of menstrual irregularities. Beginning antiretroviral therapy with any level of HIV-related wasting will help restore weight, which may help regulate periods.
The bottom line is that changes in your menstrual pattern should always be discussed with your healthcare provider so that appropriate tests can be done to determine the cause.
Hormonal therapies
Low levels of the hormone testosterone have been linked to HIV-related wasting syndrome. This can affect menstrual cycles, but may improve with testosterone replacement therapy.
For irregular periods, the use of birth control pills to help restore regularity and reduce heavy bleeding may be recommended. Estrogen and progesterone hormone replacement therapy (HRT) is sometimes recommended before menopause, especially when symptoms are very severe. Because of concerns about the possible risks of cancer with long-term hormone replacement therapy, short-term use for the specific relief of symptoms is preferred. Any hormone replacement therapy should be thoroughly discussed with your healthcare provider. Possible interactions with other medications also need to be discussed.
Premenstrual symptoms
Physical and emotional symptoms can develop during the lead up to your period and can continue throughout it. Almost all people who menstruate experience some degree of premenstrual symptoms, and many people living with HIV have reported increased and more intense symptoms. There are many remedies for relief of premenstrual symptoms; you may have to try several different ones before finding something that works for you.
The good news is that it is possible to greatly decrease or even eliminate premenstrual symptoms. You may find it helpful to keep a diary of how you feel, physically and emotionally, before you start anything new and for several months afterward. This can help tell you what’s working and what isn’t, and can help keep track of symptoms in case you need to talk to your healthcare provider.
Exercise and diet
Regular physical exercise can help to relieve premenstrual symptoms. A regular exercise program is an important part of a healthy lifestyle. If exercise is not currently part of your lifestyle, knowing that it can help reduce premenstrual symptoms can be a reason to start.
Many experts recommend cutting down or cutting out caffeine, sugar, salt and alcohol to help with premenstrual symptoms. Reducing salt in the diet has been shown to help cut down on water retention and the sensation of being uncomfortably bloated. It can be difficult to find salt-free foods, but by cooking your own meals, looking for salt-free foods and reading the labels on food packages for sodium content, it is possible to reduce your salt intake.
Cutting back on caffeine can also help. Caffeine can increase the anxiety and irritability associated with premenstrual symptoms. Remember that caffeine is found not only in coffee and tea, but also many soft drinks, chocolate and many over-the-counter medications. Alcohol has also been shown to worsen headaches, fatigue and depression in people with premenstrual symptoms. If you drink alcohol, consider reducing or eliminating your intake during this time to reduce premenstrual symptoms.
Consuming carbohydrates may result in an increase in serotonin (the brain’s “happiness” chemical) and can help to reduce tension, depression and anger in people experiencing premenstrual symptoms. Any combination of foods that raises the blood levels of tryptophan will work because tryptophan stimulates the production of serotonin. High-carbohydrate foods, such as whole-grain toast or hot cereal, as well as protein foods that are high in tryptophan, such as dairy products and turkey, will raise serotonin levels.
Adding carbohydrate-rich snacks for a few days before or during your period can sometimes help lessen the emotional distress that can accompany periods. However, if you add these carbs day after day, weight gain can occur unless you increase your level of exercise. Don’t forget to speak to your healthcare provider about persistent emotional problems and safe ways of finding relief from them.
Supplements
Several micronutrient supplements can be helpful with premenstrual symptoms.
Magnesium can help reduce or eliminate painful cramping. It can also be useful to counter irritability and moodiness. A safe dose to start with is 250 to 350 mg per day. Higher doses can cause diarrhea but may be needed for effective relief. Magnesium glycinate may be better tolerated than other forms of magnesium.
For painful or swollen breasts, vitamin E is often very useful. A daily dose of 800 to 1,200 IU may reduce symptoms when taken the week before your period starts and during your period. The dosage required to counter these symptoms varies from person to person, so speak to a healthcare provider. Be sure your supplement contains the full range of compounds (called mixed tocopherols) that belong to the vitamin E family.
The supplement 5-hydroxytryptophan (5-HTP) is related to tryptophan and converts directly to serotonin. It can help relieve the emotional symptoms of the premenstrual period. It is important to take 5-HTP with vitamin B6 because this vitamin is deficient in many people living with HIV, and is used to convert 5-HTP to serotonin. Many 5-HTP products contain vitamin B6. However, 5-HTP should never be taken by people also taking medicines for treating depression or anxiety. The combination of 5-HTP with these other meds can cause serious, even life-threatening side effects Speak to your pharmacist so that they can review all the medicines and supplements you are taking and find out if 5-HTP or other supplements are safe for you.
A daily supplement of vitamin B6 can help reduce water retention and bloating. It should be taken along with a B complex supplement to help keep B vitamins in balance. It also seems to help reduce mood dysregulation associated with premenstrual symptoms.
Gamma-linolenic acid (GLA), found most cheaply in borage oil supplements as well as in evening primrose oil supplements, may help with breast pain, bloating and emotional symptoms such as irritability and depression. A dose of 240 mg, taken twice daily, is a common recommendation from naturopathic healthcare providers to reduce premenstrual symptoms.
Calcium supplementation may ease symptoms such as water retention and moodiness. Since the average person gets only 550 mg daily from their diet, temporary calcium supplementation may be useful. However, before taking supplements, try and eat more calcium-rich foods. If this is too difficult, speak to your healthcare provider about your calcium needs.
Herbs
Herbs like black cohosh, raspberry root or rue can help relieve premenstrual symptoms in some people. However, some herbs can interact with various medications. Before starting any herbal therapies, consult a healthcare provider or herbalist and, if possible, a pharmacist highly knowledgeable about HIV.
Over-the-counter and prescription drugs
Naproxen (Aleve, Anaprox), mefenamic acid (Ponstan) and ibuprofen (Advil, Motrin) are anti-inflammatory drugs that relieve cramps and can reduce premenstrual symptoms. They are available over the counter from your pharmacist. Talk to your healthcare provider about using these sorts of drugs, especially if you are taking tenofovir-containing medicines (Viread and in Truvada, Descovy, Biktarvy, Genvoya, Atripla, Complera, Delstrigo, Stribild) as there is a risk of kidney injury.
Several prescription drugs are sometimes recommended for severe emotional premenstrual symptoms. Some antidepressants can improve mood swings, irritability and depression by boosting serotonin levels in the brain. These medications have the potential for side effects, so be sure to discuss your options thoroughly with your healthcare provider.
Drug interactions
Make sure you discuss your use of any products, including multivitamin-mineral supplements, herbal and other complementary therapies, over-the-counter products and prescription drugs, with your healthcare provider and pharmacist before taking them. Some products can interact with HIV medications and lead to increased side effects or cause the antiretroviral drugs to be less effective. Mineral supplements, including calcium and magnesium, may need to be taken separately from certain HIV medications. Speak with your pharmacist and healthcare provider to understand how best to take all your medications and natural health products.