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Menopause and HIV: Clinical Characteristics, Symptoms, and Management

This article discusses the clinical characteristics of perimenopause, menopause, and post-menopause in HIV-infected women, as well as the impact of HIV infection and/or management on menopausal symptoms and health risks. It also provides resources for clinical guidance on managing symptoms in this population.

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Menopause and HIV: Clinical Characteristics, Symptoms, and Management

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  1. Menopause and HIV: 101 Nikole D. Gettings, MSN, CNM Director of Clinical Services CHOICES ngettings@memphischoices.org 901-274-3550

  2. Objectives Define clinical characteristics of perimenopause, menopause and post-menopause, as well as other causes of amenorrhea or ovarian failure Identify common patient reported menopausal symptoms in HIV-infected population Identify health risks associated with menopause and the impact of of HIV-infection and/or HIV-management on these health risks Identify resources for clinical guidance on the impact of HIV-infection and/or HIV management on symptoms and management of symptoms in peri-/post-menopausal HIV-infected population

  3. Menopause Statistics 40 million women in the next decade Women’s life expectancy: 81.7 Tripling of women over age 50 in last 100 years

  4. Menopause • Retrospective: 12 consecutive months of amenorrhea, not caused by surgery • W.H.O. • correlated FSH levels >25 or 35 MIU/ML • No longer fertile • No longer able to release eggs

  5. Hypothalmus-Pituitary-Brain Axis Brain: Body Temperature Memory loss Reproductive hormones Bone Mineral density Breast Puberty Lactation Cancer Heart and Liver Cholesterol Build up of Plaque Ovary Maturation of follicles Uterus Maturation Endometrial thickening Cancer Vagina Maturation Lubrication

  6. Perimenopause The Stages of Reproductive Aging Workshop (STRAW): variation in menstrual cycle length in a woman with elevated FSH 3 or more consecutive months of amenorrhea in a year, but less than 11 Fluctuation in “reproductive hormones”

  7. Ovarian Failure • Follicle depletion (Permanent) • Chromosomal abnormality: Turner’s syndrome, fragile X • Toxins: Chemotherapy, medications, cigarette smoke, chemicals, pesticides • Follicle Dysfunction (Reversible) • Extremely low BMI (>18) • Thyroid disorders • Immune system disorders

  8. Pregnancy/Pregnancy Loss Most common period of life to experience an unexpected, unplanned pregnancy

  9. Phases of Perimenopause

  10. Common Symptoms of Perimenopause flashes/Night Sweats: Vasomotor Urinary incontinence Sleeping disorders Sexual dysfunction Depression Anxiety Labile mood Memory loss Fatigue Headache Joint pains Weight gain

  11. Postmenopausal Health Effects Cardiovascular disease Diabetes Osteoporosis Fertility

  12. Questions

  13. Menopause + HIV

  14. HIV or Menopause Menopause Signs of HIV + Hot Flashes Night sweats Mood liability Vaginal dryness Sleep disturbances Memory loss depression lack of energy or fatigue weight loss frequent low-grade fevers and night sweats frequent yeast infections (in the mouth) skin rashes or flaky skin that is hard to heal short-term memory loss

  15. HIV Statistics (2007)

  16. Research Topics: HIV and Menopause Age at menopause Menopausal Symptoms Reproductive Hormones Cognitive Function Bone mineral density Lipid metabolism Glucose metabolism Impact of HAART on CD-4 and Viral Loads Imai, K., et al (2013)

  17. Age of Menopause: 46-50 Average age 2-3 years younger than historical studies on White, middle class

  18. Early Age of Menopause Early Menopause HIV + Cigarette smoking Low socioeconomic markers Low level of education Unemployment African American Psychological stress Heroin/cocaine use Physical inactivity 70% of HIV positive women smoke cigarettes HIV affects lower socioeconomic people disproportionately Unemployment disproportionately affects HIV + In 2006, the rate of new HIV infection for black women was nearly 15 times as high as that of white women and nearly 4 times that of Hispanic/Latina women. Reports of high prevalence of drug use among HIV + Calvet, G.; Grinnsztejn, BGJ, Quintana MSB; et al (2014). Predictors of early menopause in HIV-infected women: a prospective cohort study. American Journal of Obstetrics & Gynecology. 212:1.e1-1.e13

  19. Menopausal Symptom Report in HIV + Attitudes toward menopause Increased report of hot flashes Increased report of vaginal dryness Earlier report of symptoms Lui-Filho, et al. (2013)

  20. Most Menopause Symptoms Economic hardship Unemployment Low socioeconomic status More than 3 negative life events

  21. HIV-Infected Menopausal Care: Symptom Management HIV-Infected Non-HIV Infected HRT Oxybutynin ER SSRI Gabapentin Omega Fish Oils Exercise Yoga Acupuncture Herbal Remedies: ? benefit • HRT* • Oxybutynin ER* • SSRI: Monitor/Caution • Gabapentin: Monitor/Caution • Omega Fish Oils • Exercise • Yoga • Acupuncture • Herbal Remedies: NO McPheeters, C.; Gregg, J. (2013). Treatment options for hot flashes in the HIV-Positive menopausal patient. The Journal for Nurse Practitioners. 9(3): 166-171

  22. Cognitive Function and HIV-Infection Depression Anxiety Low education Baseline mental or personality abnormalities HIV associated Dementia: low CD4, anaemia, low BMI, age, injection drug use, female Access to HAART

  23. Cognitive Function • Consensus: Menopause is not consistently associated with memory loss, Hormone replacement therapy (HRT) does not improve

  24. HIV-Infected Menopausal Care: Cognitive Function Social Engagement Intellectual Stimulation: Games, Puzzles Meaningful work/volunteer Community and Family Roles

  25. BMD and HIV + Increased prevalence of low bone mineral density Increased osteopenia Increased incidence of Osteoporosis Fractures? David, A.; Kulkarni, M.; Borkar, A.; et al. (2014). Prevalence of low bone mineral density among HIV patients on long-term suppressive antiretroviral therapy in resource limited setting of western India. Abstracts of the HIV Drug Therapy Glasgow Congress 2014. Journal of the International AIDS Society. 17(Suppl 3):19567

  26. HIV-Infected Menopausal Care: Bone Mineral Density David, A.; Kulkarni, M.; Borkar, A.; et al. (2014). Prevalence of low bone mineral density among HIV patients on long-term suppressive antiretroviral therapy in resource limited setting of western India. Abstracts of the HIV Drug Therapy Glasgow Congress 2014. Journal of the International AIDS Society. 17(Suppl 3):19567 Resistance Exercise Vitamin D Supplementation Calcium Supplementation Early ART: lower baseline CD4 prior to (HA)ART: low BMD

  27. Lipid Metabolism/Glucose Metabolism

  28. Lipid/Glucose Abnormalities

  29. Lipid Metabolism/Glucose Metabolism

  30. HIV-Infected Menopausal Care: Lipid and Glucose Metabolism Weight Control Cardio Exercise Omega 3 Fatty Acids/Fish Oil Screening for HTN and DM Treatment with monitoring for adequate control of HTN and/or DM when indicated

  31. HIV-Infected Menopausal Care: Reproductive Health Care Baldwin, M.; Jensen, T.; (2013). Contraception during the perimenopause. Maturitas, 76:235-242; Kim, SC, et al. (2013). Effect of Highly Active Antiretroviral Therapy (HAART) and Menopause on Risk of Progression of Cervical Dysplasia in Human Immune-Deficiency Virus-(HIV-) Infected Women. Infectious Diseases in Obstetrics and Gynecology. http://dx.doi.org/10.1155/2013/784718 Taylor, T.; Weedon, J.; Golub, E.; et al. (2014) Longitudinal trends in sexual behaviors with advancing age and menopause among women with and without HIV-1 Infection. AIDS Behavior. DOI: 10.1007/s10461-014-0901-1 Contraception STI Screening and treatment if indicated Healthy Sexuality PAP Smears/Cervical Health Breast Mammography

  32. PostMenopausal Health Risks Postmenopause Postmenopause + HIV + HAART Cardiovascular disease Diabetes osteoporosis Dyslipidemia Insulin resistance osteopenia

  33. HIV-Infected and Menopause: Clinical Care

  34. Resources • The Well Project (Updated August 2014). Menopause and HIV. Accessed online at http://www.thewellproject.org/hiv-information/menopause-and-hiv • Project Inform (January 2013). HIV and older age. Wise Words; 10:1-8. Accessed online at http://www.thebody.com/content/art61732.html • The Boston Women’s Health Book Collective, Our Bodies, Ourselves.

  35. Advice: HIV-Infection and Menopause • Stay active • Maintain healthy weight • Hormone replacement therapy for short term symptom management • Eat a balanced diet • Routine health screenings for cervical cancer, breast cancer, cholesterol, blood pressure • Calcium and Vit D Supplementation • Stay engaged • Long-term, stable partner • No ETOH

  36. Best Advice: Have a Healthy Mom

  37. Case Study # 3: Is this MenopauseJanelle 47 yo AA female Irregular bleeding No vaginal bleeding x 6 months “Like a regular period” August/September October: sudden onset of heavy bleeding x 2 days, then stopped Currently week prior to Thanksgiving: no bleeding so far Other symptoms: having night sweats

  38. Case Study # 3: Is this MenopauseJanelle PMH Medications Family History Social History Sexual Health History

  39. Case Study # 3: Is this MenopauseJanelle Bleeding Assessment A) Dysfunctional Uterine Bleeding B) Menopause C)Pregnancy/Loss D)Perimenopause

  40. Case Study # 3: Is this MenopauseJanelle What would be a treatment option for Janelle’s hot flashes/night sweats? A) SSRI B) Acupuncture C) Yoga D) HRT

  41. Case Study # 3: Is this MenopauseJanelle When you counsel Janelle re: expectations of how long her irregular bleeding will last, which is the most likely? A) 6 months B) 1-2 years C) 3-5 years D) For the rest of her life

  42. Case Study # 3: Is this MenopauseJanelle Which treatment options for Janelle’s episodes of heavy bleeding does she have the LEAST contraindication? A) Paragard IUD B) Mirena IUD C) Lysteda D) Ibuprofen prn

  43. Case Study # 3: Is this MenopauseJanelle Pearl: “The healthcare professionals responsible for treating retroviruses often neglect to treat menopausal signs and symptoms” Lui-Filho, et al (2013)

  44. References ACOG (2010). Practice bulletin number 117: Gynecologic care for women with human immunodeficiency virus. Obstetrics & Gynecology; 116(6): 1492-1509. Arnsten, J., et al. (2006). HIV infection and bone mineral density in middle-aged women. Clinical Infectious Diseases; 42: 1014-20. The Boston Women’s Health Book Collective, Our Bodies, Ourselves. 2005 ed. Simon & Schuster, NY, NY. Conde, D., et al. (2009). HIV, reproductive aging, and health implications in women: a literature review. Menopause: The Journal of The North American Menopause Society; 16(1): 199-213. Fan, M., et al. (2008). HIV and the menopause. Menopause International; 14: 163-68. Hartel, D., et al. (2008). Attitudes toward menopause in HIV-infected and at-risk women. Clinical Interventions in Aging; 3(3): 561-66. Kamemoto, L. (2003). Hormones, Menopause, and HIV infection. Menopause Management; 8-12. Available online at: http://www.menopausemgmt.com/issues/12-05/Kamemoto.pdf Milunka, E., Wang, C., and Cu-Uvin, S. (2007). HIV and menopause: A review. Journal of Women’s Health; 16(10): 1402-11. Perez, J. and Moore, R. (2003). Greater effect of highly active antiretroviral therapy on survival in people aged > 50 years compared with younger people in an urban observational cohort. Clinical Infectious Diseases; 36: 212-8. Project Inform (2002). HIV and older age. Wise Words; 10:1-8. Accessed online at http://www.thebody.com/content/art5137.html Santoro, N., et al. (2009). Women and HIV infection: The makings of a midlife crisis. Maturitas; 64(3): 160-64. Available online at Schoenbaum, E., et al. (2005). HIV infection, drug use, and onset of natural menopause. Clinical Infectious Diseases; 41:1517-24. The Well Project (Updated April 2011). Menopause and HIV. Accessed online at http://www.thewellproject.org/en_US/Womens_Center/Menopause.jsp

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