Clinical Review

Menopause in HIV-Infected Women

Journal of Clinical Outcomes Management. 2016 January;23(1)

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Vasomotor symptoms can be severely distressing with hot flashes contributing to increased risk of depression [56,60]. In a cross-sectional analysis of 835 HIV-infected and 335 non–HIV-infected women from the WIHS, persistent vasomotor symptoms predicted elevated depressive symptoms in both HIV-infected and non-HIV-infected women [60]. In a similar cross-sectional analysis of 536 women, among whom 54% were HIV positive and 37% were perimenopausal, psychological symptoms were prevalent in 61% of the women with vasomotor symptoms [56].

Oddly enough, higher CD4 cell counts appear to be associated with increased prevalence of vasomotor symptoms [39,56]. Clark et al demonstrated that menopausal HIV-infected women with CD4 cell counts > 500 cells/mm ³were more likely to report hot flashes [39]. Similarly, Miller et al observed a reduction in the prevalence of menopausal symptoms as CD4 cell counts declined among HIV-infected non-HAART users [56]. The rationale behind this is unclear but some experts postulated that it may be due to the effects of HAART.

Genitourinary Symptoms

With estrogen deficiency, which accompanies the perimenopausal period, vulvovaginal atrophy (VVA) occurs leading to symptoms of vaginal dryness, itching, burning, urgency, and dyspareunia (painful intercourse) [59,61,62]. Unlike vasomotor symptoms, which diminish with time, genitourinary symptoms generally worsen if left untreated [63]. Furthermore, these symptoms are often underreported and underdiagnosed [64,65]. Several studies using telephone and online surveys have found that the prevalence of symptoms of VVA is between 43% and 63% in postmenopausal women [66–69]. Even higher rates were found in the Agata Study in which pelvic exams in 913 Italian women were performed to obtain objective signs of VVA [62]. The prevalence of VVA was 64% 1 year after menopause and 84% 6 years after menopause. Vaginal dryness was found in 100% of participants with VVA or 82% of total study participants. In addition, 77% of women with VVA, or 40% of total study participants, reported dyspareunia.

Genitourinary symptoms are most common among women who are African American, have an increased BMI, are from lower socioeconomic class, use tobacco [19], have prior history of pelvic inflammatory disease, and have anxiety and depression [70,71]. Similarly to hot flashes, many of these predisposing factors are more common in HIV-infected women. Fantry et al found that 49.6% of HIV-infected women had vaginal dryness. Although 56% of postmenopausal women and 36% of perimenopausal women complained of vaginal dryness, in a multivariate analysis only cocaine use, which can decrease estradiol levels [7,31] was associated with a higher frequency of vaginal dryness [40].

Similarly, dyspareunia is also common among HIV-infected women. In a cross-sectional study of 178 non–HIV-infected and 128 HIV-infected women between 40 and 60 years of age, Valadares et al found that the frequency of dyspareunia in HIV-infected women was high at 41.8% [72]. However, this was not significantly higher compared to the prevalence of 34.8% in non–HIV-infected women. HIV infection itself was not associated with the presence of dyspareunia

Psychiatric Symptoms

Anxiety and depression are also common symptoms in perimenopausal women [73–76]. Studies have shown that depression is diagnosed 2.5 times more frequently among perimenopausal than premenopausal women [76].