Menopause and HIV—their impact on cognition

As women age, their bodies undergo complex changes that affect many aspects of their health. Menopause is one such change, driven by altered hormonal levels. The ovaries produce estrogens, estradiol and estrone, and at around age 35 they begin to shrink. On average, by the age of 50, the production of estrogen has significantly decreased while the production of other hormones, LH and FSH, are on the rise. As women approach menopause, changing hormone levels can cause symptoms such as the following:

• hot flashes
• night sweats
• irregular periods with changes in bleeding
• vaginal dryness

Some women have reported the following symptoms as they transition through menopause:

• mood swings
• depression
• difficulty concentrating
• poor memory
• sexual dysfunction

The intensity and duration of these symptoms associated with the body’s entry to menopause can vary considerably from one woman to another.

Research on menopause

Scientists across the U.S. have been studying the intersection of menopause in women with HIV and in women at high risk for this infection. In particular, research teams have focused on the impact of menopause on neurocognitive functioning and mental and emotional health. They found that HIV-positive women undergoing menopause who had symptoms of anxiety were more likely to perform poorly on assessments of neurocognitive functions. The negative effect of anxiety was greater than that of HIV in this study. The researchers encourage doctors caring for HIV-positive women to screen them for anxiety and, if present, to treat it.

Study details

Researchers in the following cities enrolled women with HIV and women at heightened risk for this infection:

• Bronx
• Brooklyn
• Chicago
• Los Angeles
• San Francisco
• Washington, DC

For this study the researchers focused on the following women:

• 708 who were HIV positive
• 278 who were HIV negative

Women underwent surveys, interviews, neurocognitive assessments, physical exams and blood tests. This report will focus on the outcomes in HIV-positive women.

At the time of the study (between April 2007 and April 2008) the average profile of the HIV-positive women was as follows:

• age – 44 years
• annual income of US$12,000 or less – 48%
• tested positive for hepatitis C virus antibodies – 32%
• a history of using crack, cocaine or heroin – 50%
• currently used crack, cocaine or heroin – 11%
• engaged in what the researchers called heavy alcohol use – 15%
• currently smoked tobacco – 44%
• lowest-ever CD4+ count – 233 cells/mm³
• CD4+ count greater than 500 cells/mm³ – 43%
• 95% or greater levels of adherence to ART – 48%
• HIV viral load less than 50 copies/ml – 51%

Results—Stages of menopause

The distribution of women in the different stages of menopause was as follows:

• 56% were in premenopause
• 15% were in early perimenopause
• 5% were in late perimenopause
• 24% were postmenopausal

Here are the proportions of women with different symptoms associated with menopause:

• depression – 35%
• anxiety – 9%
• sleep disturbances – 29%
• hot flashes and/or night sweats – 18%

When researchers analysed the symptoms of menopause and linked these symptoms to stages of menopause, they found the following:

• Women with early perimenopause were significantly more likely to report symptoms of depression and anxiety than premenopausal women.
• Postmenopausal women were more likely to report problems concerning sleep than premenopausal women.

Results—Neurocognitive assessments

Researchers found that HIV-positive women who had what they described as “elevated anxiety symptoms” performed poorly on several different assessments of neurocognitive functioning compared to other HIV-positive women without symptoms of anxiety. These differences were statistically significant, that is, not likely due to chance alone. The negative effect of anxiety was greater than that of depression among HIV-positive women.

Furthermore, among HIV-positive women, researchers found that the impact of anxiety on assessments of neurocognitive functioning was “generally” greater than the impact of HIV.

Digging deeper

Researchers sought to identify specific anxiety-related feelings that were linked to poorer neurocognitive functioning. They found that the following emotions were mentioned by women:

• “feeling tense/nervous”
• experiencing greater feelings of “fearfulness for no reason”

Bear in mind

The present study was cross-sectional in nature. This type of study is analogous to a snapshot taken at one point in time. Cross-sectional studies are sometimes done as a first step to explore a research question. The results can sometimes provide the justification needed for a larger, longer and more expensive study. However, cross-sectional studies cannot provide definitive conclusions about health conditions. For instance, in the present study, researchers assumed that symptoms of anxiety and depression led to decreased neurocognitive functioning. However, it is possible that in some women, problems with neurocognitive functioning could have occurred before the onset of anxiety and depression.

The U.S. researchers now have a long-term study underway to better understand why some HIV-positive women develop neurocognitive problems and the impact of menopause on these issues.

They also encourage doctors caring for HIV-positive women to screen them for anxiety and, if present, to offer treatment.

—Sean R. Hosein

REFERENCE:

Rubin LH, Sundermann EE, Cook JA, et al. Investigation of menopausal stage and symptoms on cognition in human immunodeficiency virus-infected women. Menopause. 2014; in press.