HIV Care Shaped by Menopause as Women Age

Marcia Frellick

November 08, 2019

BASEL, Switzerland — Sophie Strachan's menopause "nightmare" started at age 44, the same time she wanted desperately to have a child with her partner.

Strachan, who was diagnosed with HIV in 2003 and is chair of the Sophia Forum, an advocacy group in the United Kingdom for women living with HIV, said she originally got much of her knowledge about menopause from Twitter.

Menopause was not even on her radar at that age, she explained; she thought it would start in her 50s. She began experiencing insomnia, mood swings, irritability, and even suicidal feelings, and had trouble separating whether the feelings came from life stresses, menopause, or HIV.

"Nothing prepared me for this. At all," she said during her presentation here at the European AIDS Conference 2019. "Do not underestimate how debilitating and devastating menopause can be for some women."

Strachan said she resents the label "complex" for women who have a mix of conditions and experiences such as hers. When she was grieving the end of a longtime dream to give birth, she was told she could always adopt or foster. That's not what she wanted to hear, she explained, and recommended that physicians be sensitive and try to understand that women entering menopause might be mourning a loss.

When she began her transition into menopause, she didn't know there were specialty clinics. "If you do know about them, please tell your patients," she told members of the audience.

She also urged training for all healthcare professionals on the management of menopause, and suggested that they start talking to women about what to expect when patients are in their 30s. Additionally, researchers should lower their age cutoffs to 40 years, instead of 45, so that women in early menopause are included in menopause studies, she added.

Do not underestimate how debilitating and devastating menopause can be for some women.

The number of women 45 to 60 years under care for HIV in the United Kingdom increased fivefold from 2006 to 2016, said Shema Tariq, MBBS, PhD, from the University College London Institute for Global Health.

This increase is likely related to improvements in diagnosis and treatment that increase the lifespan of people with HIV, she explained.

But research on menopause in HIV is lacking, and many primary care physicians don't have the confidence to treat menopause in this population, Tariq told Medscape Medical News.

This was demonstrated in a 2017 survey conducted by Tariq and her colleagues, in which 97% of the primary care physicians who responded reported confidence in managing menopause in general, but that dropped to 47% for women with HIV (P <  .001).

And anecdotal reports from primary care physicians indicate that they do not feel confident managing drug–drug interactions with antiretroviral medications and don't know enough about the risks of hormone-replacement therapy in women with HIV.

"Actually, the HRT risk is no different than for women without HIV, so it's all about education," Tariq explained.

This lack of confidence results in patients being bounced back and forth between specialists and primary care, she said.

"I'm not saying that primary care physicians should take over menopause management," she explained, "but we should be supporting our primary care colleagues."

That support should extend to primary care physicians treating patients with HIV who also have hypertension or diabetes, she added.

Special Concerns With HIV

The Positive Transitions Through the Menopause (PRIME) study of 869 pre-, peri-, and postmenopausal women with HIV in the United Kingdom showed that 78% of participants reported psychological problems during menopause, including depression, anxiety, irritability, and exhaustion, said Tariq, who was the primary PRIME investigator.

The study also showed that almost half the women said they didn't have sufficient information about menopause.

Research has shown that psychologic and vasomotor symptoms (primarily hot flashes) associated with menopause are more troublesome in women with HIV than in those without, and risk for osteoporosis, fractures, and cardiovascular events is elevated.

"This isn't just a nuisance that happens to women in their 40s," said Tariq. "We have a real opportunity for preventive healthcare. We can review their health more broadly and evaluate their cardiovascular risk, their bone risk, and their psychological wellbeing."

In the updated EACS guidelines, which were presented at the meeting, it is recommended that clinicians assess menopausal status in women 40 years and older during their first HIV visit.

Updated Guidelines

"The feeling is that we might miss menopause with other comorbidities and treatment," said Justyna Kowalska, MD, PhD, from the Medical University of Warsaw in Poland.

"People think symptoms might be related to the antiretroviral drugs. We are responding not just to research, but also to consultations with community representatives," Kowalska told Medscape Medical News.

She said she agrees with Tariq that care needs to be consolidated. In Poland, she pointed out, gynecologists care for menopausal women with HIV, not primary care physicians.

"The best model is caring for HIV-positive women with a holistic approach and having clinics that integrate gynecologist care and HIV specialists so that menopause can be handled there," Kowalska said.

European AIDS Conference (EACS) 2019. Presented November 6, 2019.

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