Menopause in HIV-Infected Women

HIV-infected women have several factors associated with early menopause which are similar to that in the general population, including African American race, injection drug use, cigarette smoking, and menarche before age of 11 [37,41]. In addition, multiple studies have shown that a key factor associated with early age of menopause among HIV-infected women is the degree of immunosuppression [37,41,45]. The Ms Study found that women with CD4 cell counts < 200 cells/mm ³ had an increased risk ofamenorrhea lasting at least 12 months when compared to women with CD4 cell counts ≥ 200 cells/mm ³. The median age of menopause was 42.5 years in women with CD4 cell counts < 200 cells/mm ³, 46.0 years in women with CD4 cell counts between 200 cells/mm ³ and 500 cells/mm ³, and 46.5 years in women with CD4 cell counts > 500 cells/mm ³ [45]. Similarly, in a cohort of 667 Brazilian HIV-infected women, among whom 160 women were postmenopausal, Calvet et al found 33% of women with CD4 cell counts < 50 cells/mm ³ to have premature menopause, compared to 8% of women with CD4 cell counts ≥ 350 cells/mm ³ [41]. De Pommerol et al studied 404 HIV-infected women among whom 69 were found to be postmenopausal. They found that women with CD4 cell counts < 200 cells/mm ³ were more likely to have premature menopause compared to women with CD4 cell counts ≥ 350 cells/mm ³ [37].

Besides the degree of immunosuppression, another factor contributing to early menopause unique to HIV-infected women is chronic hepatitis C infection [41].

Menopause-Associated Symptoms

The perimenopausal period, which begins on average 4 years prior to the final menstrual period, is characterized by hormonal fluctuations leading to irregular menstrual cycles. Symptoms associated with these physiologic changes during the perimenopausal period include vasomotor symptoms (hot flashes), genitourinary symptoms (vaginal dryness and dyspareunia), anxiety, depression, sleep disturbances, and joint aches [46–53]. Such menopausal symptoms can be distressing, negatively impacting quality of life [54].

It can be difficult to determine which symptoms are caused by the physiologic changes of menopause in HIV-infected women as they have multiple potential reasons for these symptoms, such as antiretroviral therapy, comorbidities, and HIV infection itself [55]. However, several studies clearly show that there are symptoms that occur more commonly in the perimenopausal period and that HIV-infected women experience these symptoms earlier and with greater intensity [38–40,42,56,57]. In a cross-sectional study of 536 women among whom 54% were HIV-infected, Miller et al found that menopausal symptoms were reported significantly more frequently in HIV-infected women compared with non–HIV-infected women [56]. As symptoms can occur in greater intensity and impair quality of life, it is important that providers be able to recognize, understand, and appropriately treat menopausal symptoms in HIV-infected women.

Vasomotor Symptoms

In the United States the most common symptom during perimenopause is hot flashes, which occur in 38% to 80% of women [58,59]. Vasomotor symptoms are most common in women who smoke, use illicit substances, have a high BMI, are of lower socioeconomic status, and are African American [19]. As expected, prior studies focusing on hot flash prevalence among premenopausal, perimenopausal, and postmenopausal HIV-infected women found that postmenopausal women experience more hot flashes than premenopausal or perimenopausal women [40,42]. In addition, a comparison of HIV-infected and non–HIV-infected women demonstrated a higher prevalence of hot flashes among HIV-infected women [38,56]. Ferreira et al found that 78% of Brazilian HIV-infected women reported vasomotor symptoms compared to 60% of non–HIV-infected women [38]. Similarly, Miller et al reported that 64% of HIV-infected women reported vasomotor symptoms compared to 58% of non–HIV-infected women [56].