Menopause and HIV

Anyone with ovaries (the reproductive organ that produces eggs) will experience the menopause – including cisgender women, transgender men and non-binary people. The menopause is when periods stop because the ovaries no longer work. It is a natural part of ageing and usually happens between the ages of 45 and 55. Periods become less frequent over a few months or years, before they stop altogether.

The time of change leading up to your last menstrual period is called the ‘perimenopause’. The menopause begins after you have had your last period.

The menopause is caused by a change in the balance of the body’s sex hormones, which occurs as you get older. The ovaries produce less of a hormone called oestrogen and no longer release an egg every month. After this, you are no longer able to get pregnant naturally.

Going through this transition is viewed differently by those who experience it. Some view it as a ‘third age’ and celebrate no longer having periods or premenstrual syndrome (PMS). Others find it difficult, especially if they experience troubling symptoms.

Menopausal symptoms are very common. Some people have severe symptoms that can have a significant impact on their everyday life, while others experience very mild symptoms or none at all. Symptoms can include hot flushes, night sweats, joint and muscle pain, vaginal dryness, mood changes and a lack of interest in sex.

In the UK, the average age for the menopause to begin is between 50 and 52 although some people experience the menopause earlier or later.

If menopause begins before the age of 40 this is known as premature ovarian insufficiency. Often, there's no clear cause for this.

In addition, some medical treatments and procedures can cause menopause. This includes chemotherapy and radiotherapy to treat cancer, as well as surgery to remove the ovaries.

Menopause in people living with HIV

The interaction between menopause and HIV is under-researched, but the evidence base is growing.

Women living with HIV often experience menopausal symptoms. A number of studies have found that women living with HIV are more likely to experience symptoms than women who do not have HIV. This includes sexual symptoms such as a lack of interest in sex and vaginal dryness, bodily symptoms such as hot flushes, and psychological symptoms such as depression and anxiety.

It’s not clear why this is the case. People living with HIV may be more likely to have some of the risk factors for menopausal symptoms, such as a being overweight or smoking. HIV or the immune system’s response to it may also have an impact on the ovaries and the production of hormones that affect the experience of menopause. However, research on this is limited and these conclusions are not definitive.

Some people living with HIV struggle with the additional burden of menopausal symptoms alongside managing their HIV. This can lead to difficulties adhering to HIV medication and attending clinical appointments, which can worsen their health further. If this is the case for you, speak to your HIV clinician and they can help you access treatment to make your menopausal symptoms more manageable.

Treatments to lessen the symptoms during the menopausal transition are the same regardless of whether you have HIV or not. HIV treatment works well in people going through the menopause.

Symptoms

The first sign of the menopause is usually a change in the normal pattern of your periods. There may be longer gaps between periods, and they may be unusually light or heavy. Eventually, you'll stop having periods altogether.

Knowing what else to expect during the menopause can help you deal with the symptoms you experience. It can help you tell whether a problem might be linked to your HIV treatment, HIV itself or the menopause.

It’s common to have some of these symptoms for a few years before your periods stop (the perimenopause). They may continue for up to four years after your last period, although some people have them for longer. During this time, symptoms can come and go.

The duration and severity of these symptoms vary from person to person. If you find that symptoms are bothering you or they have an impact on your daily life, speak to your doctor about treatments. The main aim of treatments for the menopause is to lessen these symptoms.

Although over 30 different menopausal symptoms have been described, the most common are:

Bodily symptoms:

• Hot flushes – short, sudden feelings of heat, usually in the face, neck and chest, which can make you sweaty.
• Night sweats – hot flushes that occur at night.
• Joint and muscle pain.
• Difficulty sleeping.

Sexual symptoms:

• Reduced interest in sex (low libido).
• Vaginal dryness and pain, itching or discomfort during sex.
• Urinary tract symptoms

Psychological symptoms:

• Problems with memory and concentration (sometimes called ‘brain fog’).
• Mood changes, such as low mood or anxiety.
• Fatigue and exhaustion.

Changing hormone levels can result in other body changes, which may have an impact on your health in the long term. You can lose up to 10% of your bone mass during the menopause process, increasing the risk of the bone-thinning disease osteoporosis and bone fractures. Since HIV also increases the risk of osteoporosis, you may be more likely to lose bone mass after the menopause than if you did not have HIV.

There is also evidence that low levels of oestrogen is the cause of some chemical changes in the body which can increase the risk of heart disease and stroke following the menopause.

Diagnosis and monitoring

Your GP should be able to tell that you have started the menopausal transition based on your symptoms, pattern of periods and age.

Tests aren't usually needed to diagnose menopause. But if you are aged 45 or under, and in some other circumstances, a blood test might be used to check your level of follicle-stimulating hormone (FSH) – high levels may be a sign of the menopause.

If you are aged over 45, your HIV doctor should also ask at least once a year whether you have experienced any menopausal symptoms or if there has been a change in your symptoms.

GPs are usually responsible for managing the menopause. However, not all GPs feel confident in managing menopause in people living with HIV, so it is fine to ask your HIV doctor for support as well. If you have severe symptoms or you are struggling to get support, you can ask to be referred to a specialist menopause centre. A doctor specialising in the menopause is usually a gynaecologist.

Treatment and management

If you are troubled by the symptoms of menopause or if they interfere with your day-to-day life, then treatments are available. The aim of treatments is to relieve symptoms and improve your quality of life.

Hormone replacement therapy (HRT) is the most effective treatment for menopausal symptoms. As symptoms such as hot flushes, vaginal dryness and osteoporosis are related to low levels of the hormone oestrogen, HRT relieves symptoms by replacing oestrogen levels that naturally fall in menopause.

Guidelines from the National Institute for Health and Care Excellence (NICE) state that hormone replacement therapy is effective and should be offered to people with menopausal symptoms, after discussing the risks and benefits. If you have had the menopause before the age of 45, hormone replacement therapy is always recommended.

There are two main types of hormone replacement therapy:

• Combined HRT (oestrogen and progestogen) is recommended if you have menopausal symptoms and still have your womb (oestrogen on its own can increase your risk of womb cancer).
• Oestrogen-only HRT is recommended if you have had your womb removed.

HRT is available in the form of tablets, skin patches, or as a gel or spray which is rubbed into the skin.

HRT comes with both benefits and risks which your doctor should discuss with you before making any decision about treatment. These benefits and risks are thought to be the same in people with HIV as for people who do not have HIV.

HRT is extremely effective at reducing menopausal symptoms and can improve your quality of life as a result. HRT also helps with muscle strength and lowers the risk of bone problems. Women who take HRT gain less abdominal fat and are less likely to develop diabetes. Oestrogen-only HRT can reduce the risk of heart disease and breast cancer, while combination HRT lowers the risk of colon and womb cancer.

However, combination HRT has been associated with an increase in the risk of breast cancer, and a very small increase in the risk of heart disease when started in women aged over 60. The increase in breast cancer risk is related to how long you take HRT, and the risk reduces after you have stopped treatment.

HRT does not make HIV treatment any less effective but some HIV drugs can interact with HRT. It’s therefore useful to tell the doctor who is prescribing your HRT about your HIV treatment as the dose of your HRT may need to be adjusted. HRT is usually prescribed by your GP but your HIV doctor or HIV pharmacist can give you advice on this too.

HRT is not suitable for everyone, especially those who have had certain types of breast cancer or are at high risk of getting breast cancer. If this is the case for you, or you decide you do not want to take HRT, there are other ways of managing menopausal symptoms.

Other ways of managing symptoms

Vaginal oestrogen. To relieve vaginal dryness, oestrogen can be administered directly to the vagina using a vaginal cream, tablet or ring. This releases a small amount of oestrogen (the equivalent of one hormone tablet a year) which raises local hormone levels but does not affect the whole body. You can safely use vaginal oestrogen on its own or in addition to HRT.

Testosterone supplements can help to restore sex drive in menopausal women. They are not currently licensed for use in women, although they can be prescribed by a doctor if they think it might help.

Non-hormonal treatments may help. These include cognitive behavioural therapy (to help with low mood or anxiety), or medicines such as clonidine (to help with hot flushes and night sweats).

Regular exercise, stopping smoking and reducing your intake of caffeinated drinks and alcohol can all also help reduce symptoms.

While some women use the herbal product St John’s wort to relieve hot flushes and night sweats, this can reduce the effectiveness of some anti-HIV drugs – ask your HIV doctor or pharmacist if it is safe for you to use.

Similarly, the herbal product black cohosh can have an impact on the liver. If your doctor knows you are taking black cohosh, they can keep an eye on your liver function.

Peer support. You may also find it helpful to talk to other women living with HIV who are also going through the menopause. Ask your clinic to find out if peer support is available in your local area.

Other issues to be aware of

Contraception. During the perimenopause there is still a chance of getting pregnant, so consider using contraceptive methods if you do not want to get pregnant. For more information, read NAM’s page on Contraception.

Bone health. It is important to take care of your bone health in the years after menopause. The British HIV Association recommends that HIV doctors regularly check the bone health of all women with HIV who have gone through the menopause. This is because both HIV and the menopause raise the risk of bone problems.

Regularly getting some weight-bearing exercise, stopping smoking, drinking less alcohol, including calcium in your diet and getting enough vitamin D are lifestyle changes that can improve your bone health. For more information, read NAM’s page on Bone problems and HIV.

Diet. A healthy diet can also help reduce the risk of heart disease, which is higher among post-menopausal women. Eating plenty of fruit, vegetables and oily fish, and cutting down on heavily processed foods, are especially important.

Information and support

For more information, you may find the following websites helpful: www.womens-health-concern.org, www.menopausedoctor.co.uk and www.managemymenopause.co.uk.