Clinical Review

Menopause in HIV-Infected Women

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

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Although studies on progression to cervical cancer in postmenopausal HIV-infected women remain limited, current data suggest that postmenopausal HIV-infected women should continue to be monitored and screened similarly to the screening recommendations for premenopausal women. Nevertheless, further studies examining the natural course of cervical lesions are needed to establish the best practice guidelines for screening postmenopausal women.

HIV Acquisition and Transmission

The incidence of new HIV infections in older American women has increased. HIV acquisition from heterosexual contact appears to be higher in older women compared to younger women, with a study suggesting that women over age 45 years had almost a fourfold higher risk of HIV acquisition compared to those under the age of 45 years [145]. While the lack of awareness of HIV risk and less frequent use of protection may contribute to increases in new HIV infection in older women, hormonal changes associated with older age, specifically menopause, may be playing a role. Vaginal wall thinning that occurs during menopause may serve as a risk factor for HIV acquisition.

In a study by Meditz et al, the percentage of endocervical or blood CD4 T cells did not differ between premenopausal and postmenopausal women, but postmenopausal women had greater percentage of CCR5 expression. As CCR5 serves as an entry point of HIV into target cells, this suggests the possibility that postmenopausal women may be at increased risk for HIV acquisition [146]. More recently, Chappell et al also revealed that anti-HIV-1 activity was significantly decreased in postmenopausal compared to premenopausal women, suggesting that there may be an increased susceptibility to HIV-1 infection in postmenopausal women [147]. Hence there appears to be menopause-related immunologic changes of the cervix that may contribute to an increased risk of HIV acquisition in postmenopausal women.

In contrast, although data is limited, postmenopausal HIV-infected women do not appear to be at increased risk of transmitting HIV to non–HIV-infected individuals. Melo et al compared the intensity of HIV shedding between premenopausal and postmenopausal women and found that HIV shedding did not differ between premenopausal or postmenopausal women [148].

HIV Progression

Several studies have focused on the effects of HIV infection on menopause, but minimal data are available on the effects of menopause on the progression of HIV infection. With prior data suggesting that younger persons experience better immunological and virological responses to HAART [149–151], it has previously been hypothesized that virologic and immunologic responses to HAART can decline once HIV-infected women reach menopause. However, current evidence suggests that treatment responses to HAART, determined by the median changes in CD4 cell counts and percentages and viral load, in HAART-naive patients did not differ between premenopausal and postmenopausal women [152]. In addition, there appears to be no significant changes in CD4 cell counts as HIV-infected women progress through menopause [153]. These studies suggest that menopause does not affect the progression of HIV and that HAART-naive women should respond to HAART regardless of their menopausal status.

Conclusion

As HIV-infected individuals live longer, increasing number of women will enter into menopause and live many years beyond menopause. HIV-infected women experience earlier and more severe menopausal symptoms, but knowledge is still lacking on the appropriate management of these symptoms. In addition, current evidence suggests that immunosuppression associated with HIV contributes to an early onset of menopause which leads to increased risks of cardiovascular disease, osteoporosis, and progression of cervical dysplasia. These conditions require proper surveillance and can be prevented with improved understanding of influences of menopause on HIV-infected women. Furthermore, although there is some evidence suggesting that menopause has no effect on HIV transmission and progression, further studies on the immunologic and virologic effects of menopause are necessary.