Clinical Review

Menopause in HIV-Infected Women


 

From the University of Maryland School of Medicine, Baltimore, MD.

 

ABSTRACT

• Objective: To review the current literature on menopause in HIV-infected women.

• Methods: We searched PubMed for articles published in English using the search terms HIV and menopause, HIV and amenorrhea, HIV and menopause symptoms, HIV and vasomotor symptoms, HIV and vaginal dryness, HIV and dyspareunia, HIV and menopause and cardiovascular disease, HIV and menopause and osteoporosis, HIV and menopause and cognition, HIV and menopause and cervical dysplasia, menopause and HIV transmission, and menopause and HIV progression. Major studies on menopause in other populations were also reviewed to provide background data.

• Results: While studies on the age of menopause in HIV-infected women give conflicting results, immuno-suppression associated with HIV appears to contribute to an earlier onset of menopause. HIV-infected women experience menopausal symptoms, especially vasomotor symptoms, earlier and in greater intensity. In addition, menopause and HIV infection have additive effects on one another, further increasing the disease risks of cardiovascular disease, osteoporosis, and progression of cervical dysplasia. The effects of menopause on HIV infection itself seems limited. While some data suggest an increased risk of acquisition in non–HIV-infected menopausal women, menopause has no effect on the transmission or progression of HIV in menopausal HIV-infected women.

• Conclusion: As HIV-infected individuals live longer, practitioners will encounter an increasing number of women entering menopause and living into their postmenopausal years. Future studies on the age of menopause, symptoms of menopause, and the effects of menopause on long term comorbidities such as cognitive decline, cardiovascular disease, and bone density loss are necessary to improve care of this expanding population of women living with HIV.

 

Since the introduction of highly active antiretroviral therapy (HAART) in 1996, there has been a significant decrease in morbidity and mortality worldwide among individuals living with human immunodeficiency virus (HIV) [1]. It is projected that by the year 2020, half of persons living with HIV infection in the United States will be over the age of 50 years [2]. For HIV-infected women, this longer survival translates into an increased number of women entering into menopause and living well beyond menopause. Enhancing our knowledge about menopause in HIV-infected women is important since the physiologic changes associated with menopause impact short- and long-term quality of life and mortality. Symptoms associated with menopause can be mistaken for symptoms suggestive of infections, cancers, and drug toxicity. Furthermore, changes in cognition, body composition, lipids, glucose metabolism, and bone mass are influential factors determining morbidity and mortality in later years.

 

Effect of HIV on the Menstrual Cycle

Menstrual irregularities, including amenorrhea and anovulation, are more frequently found in women of low socioeconomic class who experience more social and physical stress like poverty and physical illnesses [3]. In addition, women with low body mass index (BMI) have decreased serum estradiol levels which lead to amenorrhea [3,4]. Furthermore, several studies have demonstrated that methadone, heroin, and morphine use are associated with amenorrhea. Opiate use inhibits the central neural reproductive drive leading to amenorrhea even in the absence of menopause [5–7].

As these demographics, body habitus, and lifestyle characteristics are frequently found among HIV-infected women, it is not surprising that amenorrhea and anovulation are common in this population [8–14]. In fact, studies show that there is an increased prevalence of amenorrhea and anovulation among HIV-infected women when compared to non–HIV-infected women [8]. Some studies suggest that women with lower CD4 cell counts and higher viral loads have increased frequency of amenorrhea and irregular menstruation compared to those with higher CD4 cell counts and lower viral loads [9,10]. However, it remains unclear if HIV infection itself, instead of the associated social and medical factors, is responsible for the higher frequency of amenorrhea [11–13]. For example, in a prospective study comparing 802 HIV-infected women with 273 non–HIV-infected women, there was no difference in the prevalence of amenorrhea when controlling for BMI, substance use, and age [13].

The World Health Organization (WHO) currently defines natural menopause as the permanent cessation of menstruation for 12 consecutive months without any obvious pathological or physiologic causes [15]. However, given the increased prevalence of amenorrhea in HIV-infected women, amenorrhea seen with HIV infection can be mistaken for menopause. The Women’s Interagency HIV Study (WIHS), a multicenter, observational study of HIV-infected women and non–HIV-infected women of similar socioeconomic status, found that more than half of HIV-infected women with prolonged amenorrhea of at least 1 year had serum follicle-stimulating hormone (FSH) levels in the premenopausal range of less than 25 mIU/mL

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