By H. Ellis

Menopause is a natural part of aging and happens to all women. Women, on average transition to menopause at around age 50 years when their body stops producing eggs and there is a drop in the two main hormones: oestrogen and progestogen. There is also a drop in testosterone, but it is the big drop in oestrogen that causes menopausal symptoms. Women living with HIV may experience menopause earlier than women without HIV.

Symptoms of menopause include: hot flushes, night sweats, urinary tract infections (UTI), vaginosis, headaches, depression, anxiety, irritability, mood changes, sleeplessness, unusual tiredness, backache, thyroid function disorders, hair and skin changes, joint and muscle pains, low sex drive and poor mental focus ‘brain fog’. Menopause symptoms can persist due to ongoing low hormone levels which can remain low forever. Menopause symptoms (such as night sweats) can also be very similar to some early symptoms of HIV infection, which can cause women concern that their treatments are no longer controlling their HIV. Women with HIV can also experience more mental health issues than the general population, and these issues can be made worse during menopause.

Menopause symptoms and long-term health risks for women living with HIV
The reduced levels of oestrogen due to menopause has a direct impact on a woman’s long-term health. These health risks include: increased risk of heart disease, osteoporosis, type 2 diabetes, osteoarthritis, obesity, depression and dementia. However, for women with HIV when these symptoms are allowed to persist without treatment, the long-term health risks can be much worse.

Latest research shows that women with HIV experiencing untreated menopause symptoms have a greater risk of cardiovascular disease. Menopause symptoms also only add to the low level of inflammation that is already present in the body even when on HIV treatments and with an undetectable viral load, which places an additional burden on heart health. When women with HIV reach menopause, screening for these health risks, especially for osteoporosis and cardiovascular disease is needed. These screening tests include: Bone density scan and cardiovascular health checks.

Menopausal Hormone Therapy (MHT) for menopause symptoms
Treatment for menopause aims to alleviate symptoms and improve quality of life. Treatment with MHT (or Hormone Replacement Therapy – HRT) ideally needs to also include lifestyle changes such as a healthy diet and exercise (including weight bearing activity for bone health), reducing alcohol intake and stopping smoking. For some women, MHT can also include testosterone to alleviate symptoms of ongoing fatigue, poor concentration and low sex drive. There are also other non-hormonal treatments for menopause such as vaginal gels and moisturisers, which can alleviate UTIs (Urinary Tract Infections).

Latest MHT formulations are termed body identical, which are made in a lab and have the same molecular structure as the hormone produced by a woman’s body. MHT can be an oral medication or a weekly patch. The patch is either oestrogen with progesterone or just oestrogen and the progesterone taken daily as a pill. If the uterus is still intact, progesterone will prevent the uterus lining from thickening to protect against endometrial cancer. If the uterus has been removed, oestrogen only is taken. MHT is prescribed at the minimum amount to alleviate symptoms. If symptoms persist, MHT levels are increased and it may take some months to find the correct hormone levels as every woman is different.

There are many types of MHT available that are safe for women with HIV and do not interact with many of the treatments for HIV. Ideally MHT should be prescribed just before menopause begins (before periods have stopped) and in consultation with the GP, HIV specialist and a menopause specialist to ensure correct hormone levels and no drug interactions with any HIV treatments being taken.

MHT can also be prescribed within 10 years of menopause starting. A delay in starting MHT is often the case with women, including women with HIV, as there could be a year or more lag time before either the woman and her healthcare provider realise she has reached menopause.

Breast cancer risk from MHT
Lack of knowledge about the latest body identical MHT can cause concern about the risk of breast cancer while on MHT. Past research into MHT reported a possible increased risk of breast cancer, which was widely reported by the media. But in recent years, many of these studies have been shown to be inaccurate. The risk of developing breast cancer, blood clot or stroke is dependant on age, family history, smoking and level of health and fitness regardless of whether or not MHT is taken. Often the benefits of MHT in alleviating the symptoms of menopause, outweigh the risks if started before 60 and within 10 years of reaching menopause.

Resources for further information:

A Guide to Menopause for Women Living With HIV
https://sophiaforum.net/index.php/guide-to-menopause-for-women-living-with-hiv/

Watch recording: Menopause for Women Living With HIV webinar hosted by Positive Women Victoria with Dr Nneka Nwokolo (HIV and sexual health and menopause specialist)
https://positivewomen.org.au/menopause/ 

Australian Menopause Society
https://www.menopause.org.au

PODCAST
Listen to the podcast on Menopause and Women with HIV with special guest Dr Nneka Nwokolo.

Dr Nneka Nwokolo is an honorary HIV and sexual health consultant from the UK who has specialised knowledge of menopause and women living with HIV. Dr Nwokolo answers questions and outlines the latest research concerning menopause, including MHT (Menopausal Hormone Therapy), as it relates to women living with HIV.

Listen to the podcast here.

Published: June 2023