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Special Considerations in the Management of HIV in Women, Including During Conception and Pregnancy

Joseph J. Eron, Jr., MD
Program Director
Daniel R. Kuritzkes, MD
Program Director
Judith S. Currier, MD, MSc
Sigal Yawetz, MD
Released: May 21, 2020

Care of Menopausal Women With HIV

According to CDC data from 2016, nearly 50% (estimated 48%) of all people living with diagnosed HIV in the United States were 50 years of age or older.[1] Earlier estimates demonstrated that approximately 30% of women with HIV are 50 years of age or older.[2] Therefore, more women with HIV are undergoing the menopause transition. Menopause is defined as the permanent cessation of menstruation caused by the loss of ovarian function and is clinically measured as the absence of menses for 12 months in the absence of other etiologies. Biochemically, menopause is associated with a persistently elevated follicle stimulating hormone level and diminished estradiol level. Certain medical conditions, such as osteoporosis and cardiovascular disease, have been linked with estrogen deficiency. Women with HIV may be at increased risk for these conditions as well.[220,221] For example, one study suggested that vascular elasticity is lower in women,[222] and decreased estrogen and androgen levels in women with HIV may exacerbate atrial stiffness compared with women without HIV.[223] Therefore, understanding if and when a woman with HIV undergoes transition to menopause is important. Of note, symptoms associated with menopause are also commonly associated with HIV infection itself.

Age of Menopause
Earlier age of menopause has been associated with increased risk for medical diseases and increased mortality. Although the overall median age of menopause in the United States is 51.4 years,[224] there are conflicting data as to whether HIV infection is associated with an earlier onset.[225] Smoking, injection drug use, black race, and lower education level have been associated with an earlier onset of menopause in the general population.[220,226] Lower CD4+ cell count, low physical activity, and injection drug use may be associated with earlier menopause in women with HIV.[220,227]

Symptoms of Menopause
The symptoms associated with menopause appear to be similar in women with and without HIV. However, the severity of symptoms may be altered.[220,228] Black women with HIV may have more vasomotor symptoms. More severe immunosuppression is associated with diminished vasomotor symptoms. Women with depressive symptoms, reports of negative life events, and those receiving public assistance report higher rates of menopausal symptoms. Irritability, depression, emotional liability, and reduced concentration may be 25% to 50% more prevalent in women with HIV.[229]

Treatment of Menopause Symptoms
Current evidence supports the use of hormone replacement therapy for relief of menopausal symptoms, especially the vasomotor effects. However, there are no available data demonstrating safety in the HIV population.

Additional Considerations for Postmenopausal Women With HIV
Postmenopausal women should continue to undergo routine health screening which can include[230]:

  • Annual Pap smears
  • STD screening
    • Syphilis
    • Gonorrhea/chlamydia
  • Breast cancer screening
  • Colon cancer screening
  • Osteoporosis screening and prevention
    • Women should be encouraged to perform weight-bearing exercises regularly
    • 1000-1500 mg/day of calcium with 400 IU/day vitamin D
    • Annual dual energy x-ray absorptiometry screening
  • Cardiovascular risk screening
  • Depression screening

The importance of screening older adult populations for STDs may be underappreciated. However, factors that could increase the risk of acquiring an STD among older adults include the loss of a spouse[231] as well as reduced likelihood of using barrier protection among older vs younger sexual risk takers.[232] Therefore, it is important that older women as well as men are routinely screened for STDs, particularly after acquiring a new sexual partner.

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