HIV and menopause

Several years ago a team of researchers at the Albert Einstein College of Medicine in The Bronx, New York, who specialized in women’s health issues investigated menopause in HIV-positive women. As part of this investigation they reviewed relevant studies on the subject.

Age at onset of menopause

Among healthy HIV-negative women, menopause usually occurs around the age of 50. However, reports have emerged of premature menopause in some HIV-positive women. Some observational and cross-sectional studies have found early onset of menopause linked to the following factors among HIV-positive women:

• low CD4+ cell counts (less than 200 cells)
• low levels of physical activity
• use of street drugs (opiates can lower estrogen levels)
• smoking tobacco (long-term use of tobacco can also lower estrogen levels)
• having a low income

Some studies have found that Black women are more likely to have earlier onset of menopause than White women, while some studies have not found this.

Due to issues of study design, specifically the observational nature of many studies involving women and menopause, it is difficult to be certain about which factor (substance use or low income) plays a leading role in premature onset of menopause. Moreover, the Bronx researchers note that substance use and having a low income are relatively common among women with HIV infection, particularly in North America and Western Europe.

Symptoms that occur in menopause

Women transitioning into menopause can experience one or more of the following symptoms:

• breasts become tender
• hot flashes and night sweats
• difficulty falling asleep
• difficulty thinking clearly
• forgetfulness
• severe headaches
• changes in mood
• vaginal dryness
• sexual dysfunction

In some studies, HIV-positive women have reported more symptoms associated with menopause than HIV-negative women. The reasons for such differences are not clear but some researchers think they may be related to age and educational levels. For instance, in one study of HIV-negative women, those who were 45 years or older were more likely than younger women to link vaginal dryness and hot flashes to menopause. Also, HIV-negative women who graduated from high school were more likely to make the same links than women who had not also graduated from high school. Similar analyses concerning age and education and menopause have not been widely done among HIV-positive women.

One study has found that HIV-positive women were less likely to report symptoms associated with menopause to their doctors because they were not sure if menopause was responsible or if there were other ongoing health issues. This finding underscores the need for HIV-positive women to report their symptoms to their doctor so they can be investigated.

Hormonal changes

As the ovaries begin to transition to menopause, their output of hormones changes and levels of FSH (follicle-stimulating hormone) rise. A sustained increase in FSH indicates reproductive aging. Levels of another hormone, LH (lutenizing hormone), also rise while levels of estrogen fall in menopause.

In one study, researchers compared data from 82 HIV-positive women and 15 HIV-negative women. They found that HIV did not affect levels of the following hormones:

• estrogen
• prolactin
• thyroid-stimulating hormone (TSH)

Another study found that antiretroviral therapy did not affect levels of estrogen and prolactin.

Unfortunately, most studies on hormone levels in HIV-positive women did not take into account factors such as stress and substance use, which could also have affected their levels.

Bone health

In general, studies have found that HIV-positive women tend to have a greater degree of bone thinning at the hips and spine compared to HIV-negative women. Among HIV-negative women, such changes can even occur before menopause, although similar data is lacking for HIV-positive women. Moreover, studies of HIV-positive women in high-income countries have found that low levels of vitamin D in the blood are common.

Most studies have found that anti-HIV therapy (ART) generally does not accelerate bone loss over a period of several years.

Cardiovascular disease  

Research suggests that HIV infection is linked to an increased risk for cardiovascular disease (CVD) among men and women. In part, this increased risk may arise because of ongoing inflammation triggered by a chronic viral infection. As high levels of estrogen appear to have some degree of anti-inflammatory activity, it is possible that the cardiovascular system of postmenopausal women, regardless of HIV status, are more susceptible to the subtle effects of inflammation.

Bear in mind that there are many factors that incite and propel CVD, many of which can be prevented or if present managed thereby lowering a woman’s risk, including these:

• tobacco smoking
• substance use
• higher-than-normal blood pressure
• type 2 diabetes
• being overweight
• not getting enough exercise
• abnormal levels of cholesterol and triglycerides in the blood

Some studies have found an increased risk for CVD among HIV-positive women compared to HIV-positive men. The reasons for this are not clear but some doctors think that the presence of CVD risk factors may be greater in some HIV-positive women than men.

Menopause and the brain

Some women, regardless of HIV status, have reported that the transition to menopause is associated with neurocognitive changes such as difficulty thinking clearly, problems concentrating and being forgetful. Researchers have not presented a clear and robust rationale as to why reduced estrogen levels should be associated with these problems. A simple plausible explanation is that difficulty falling asleep is relatively common with the menopause transition. It is possible that women who do not get enough sleep on a regular basis do not feel refreshed and may thus have problems with memory and thinking clearly.

Some women, regardless of HIV status, may experience unexpected changes in mood—persistent sadness, anger and even depression. It is very important to alert doctors to any persistent or noticeable change in mood so that it can be assessed and, if necessary, treated.

As ART is widely available in Canada and other high-income countries, severe HIV-related cognitive problems are far less common today than before 1996. There is no evidence that HIV-positive women regardless of menopause status are more prone to cognitive problems compared to HIV-positive men.

Steps to better health

As women age, there are many simple steps they can take to stay healthy. The Bronx team of researchers encourages HIV-positive women to do the following:

• reduce alcohol and substance use
• improve their intake of healthy and nutritious food
• get support and treatment for co-existing health problems (such as co-infections, diabetes, depression)
• increase social contact by joining clubs or social groups
• increase the ability to cope with stress through activities such as regular exercise, yoga, meditation and other healthful events
• engage in activities that stimulate thinking

Much work remains to be done on women’s health in general, and HIV-positive women’s health in particular, including understanding their social, care and treatment needs as they age.

— Sean R. Hosein

REFERENCES:

1. de Pommerol M, Hessamfar M, Lawson-Ayayi S, et al. Menopause and HIV infection: age at onset and associated factors, ANRS CO3 Aquitaine cohort. International Journal of STD & AIDS. 2011 Feb;22(2):67-72.
2. Fan MD, Maslow BS, Santoro N, et al. HIV and the menopause. Menopause International. 2008 Dec;14(4):163-8.
3. Johnson TM, Cohen HW, Howard AA, et al. Attribution of menopause symptoms in human immunodeficiency virus-infected or at-risk drug-using women. Menopause. 2008 May-Jun;15(3):551-7.