Clinical Review

Menopause in HIV-Infected Women

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

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Multiple studies focusing on HIV-infected men have demonstrated an increased prevalence of fractures compared to non–HIV-infected men [124–126]. However, current studies on postmenopausal HIV-infected women demonstrate that fracture incidence is similar between HIV-infected and non–HIV-infected postmenopausal women [108,112]. Nevertheless, given the evidence of low BMD and increased fracture risk seen during menopause among non–HIV-infected women compounded with the additional bone loss seen in HIV-infected individuals, enhanced screening in postmenopausal HIV-infected women is prudent. Although the U.S. Preventive Services Task Force (USPSTF) makes no mention of HIV as a risk factor for enhanced screening [127] and the Infectious Diseases Society of America (IDSA) only recommends screening beginning at the age of 50 years old if there are additional risk factors other than HIV [128], the more recently published Primary care guidelines for the management of persons infected with HIV recommends screening postmenopausal women ≥ 50 years of age with dual-energy X-ray absorptiometry (DEXA) scan [86]. Preventative therapy such as smoking cessation, adequate nutrition, alcohol reduction, weight bearing exercises, and adequate daily vitamin D and calcium should be discussed and recommended in all menopausal HIV-infected women [129]. If the DEXA scan shows osteoporosis, bisphosphonates or other medical therapy should be considered. Although the data are limited, bisphosphonates have been shown to be effective in improving BMD [130–132].

Cognition

The menopause transition is characterized by cognitive changes such as memory loss and difficulty concentrating [133–136]. Both HIV-infected men and women are at higher risk of cognitive impairment [137–139]. Cognitive impairment can range from minor cognitive-motor disorder to HIV-associated dementia due to the immunologic, hormonal, and inflammatory effects of HIV on cognition [137–139]. In addition, those with HIV infection appear to have increased risk factors for cognitive impairment including low education level, psychiatric illnesses, increased social stress, and chemical dependence [137].

Studies focusing on the effects of both HIV infection and menopause on cognition have been limited thus far. In a cross-sectional study of 708 HIV-infected and 278 non–HIV-infected premenopausal, perimenopausal, and postmenopausal women, Rubin et al demonstrated that HIV infection, but not menopausal stage, was associated with worse performance on cognitive measures [140]. While menopausal stage was not associated with cognitive decline, menopausal symptoms like depression, anxiety, and vasomotor symptoms were associated with lower cognitive performance [140].

Though limited, current data appear to indicate that HIV infection, not menopause, contributes to cognitive dysfunction [140]. Symptoms of menopause, however, do appear to exacerbate cognitive decline indicating the importance of recognition and treatment of menopausal symptoms. This is especially important in HIV-infected women since decrease in cognition and depression can interfere with day to day function including medication adherence [141,142].

Cervical Dysplasia

As more HIV-infected women reach older age, the effects of prolonged survival and especially menopause on squamous intraepithelial lesions (SILs) are being investigated to determine if general guidelines of cervical cancer screening should be applied to postmenopausal women.

In a retrospective analysis of Papanicolaou smear results of 245 HIV-infected women, Kim et al noted that menopausal women had a 70% higher risk of progression of SILs than premenopausal women [143]. Similar results were found in a smaller retrospective study of 18 postmenopausal HIV-infected women in which postmenopausal women had a higher prevalence of SILs and persistence of low-grade SILs [144].