Abstract and Introduction
Objectives: We describe here characteristics and clinical outcomes of women living with HIV attending an HIV menopause service.
Methods: This was a retrospective case note review of women attending the monthly HIV menopause clinic from January 2015 to July 2018.
Results: In all, 55 women attended the service. The overall mean age was 49 years; 50% were black and 20% had a previous AIDS-defining condition. All were on antiretroviral therapy (ART); the median CD4 count was 678 cells/μL; 93% had a viral load < 50 copies/mL; 7% had previous hepatitis C infection; 27% had a history of smoking; 45% had risk factors or existing cardiovascular disease; 24% had a mental health condition. The median duration of symptoms before clinic attendance was 18 months. Vasomotor symptoms (84%), menstrual cycle changes (62%), psychological (56%) and urogenital symptoms (29%) were reported. Twenty-two per cent had early menopause or premature ovarian insufficiency. The mean age at attendance of women diagnosed with menopause (n = 24) was 52 years. However, their average duration of symptoms prior to review was 28 months. A total of 61% had osteopenia/osteoporosis, 73% received menopausal hormone therapy (MHT), and 73% had symptomatic improvement, although 58% of these required higher doses of MHT. Median time on MHT was 10 months. Five patients had their ART modified. No serious MHT adverse effects were observed.
Conclusions: Menopausal hormone therapy uptake was high, with most women observing an improvement in symptoms. Comorbidities were common, highlighting the need for integrated care based on a woman's needs. The long delay from initial symptoms to treatment demonstrates the need for better access to specialist advice for women experiencing menopause.
Of the approximately 100 000 people living with HIV in the UK, 1 in 3 are women, and in 2019, 12 503 women accessing HIV care were aged 45–56 years (J. Ekajeh, Public Health England, personal communication, 18 August 2021) (Figure 1) and therefore of menopausal age. Both HIV and menopause are associated with an increased risk of comorbidities, particularly osteoporosis, insulin resistance[2–4] and cardiovascular disease[5–7] and are associated with increased rates of mental ill health compared with HIV-negative, non-menopausal women.[8–10] In addition, recently published data report lower overall sexual function in HIV-positive women accessing care in England compared with HIV-negative women. The apparent effects of menopause on physical and mental health led to the publication of the British Menopause Society (BMS) vision statement for menopause care in the UK, which recommends delivery of integrated care based on the needs of the individual.
Number of women receiving HIV care by age group 2004–2019 (J Ekajeh, Public Health England, personal communication, 18 August 2021)
Data suggest that women with HIV may undergo earlier menopause and suffer more associated ill health than women without HIV. The UK PRIME study, one of the largest studies of health and well-being of menopausal women living with HIV reported a high prevalence of somatic, urogenital and psychological symptoms and low use of menopausal hormone therapy (MHT). Current MHT usage rates in PRIME study participants with somatic and urogenital symptoms were 8% and 3%, respectively. Participants also reported difficulties in accessing appropriate services to manage their menopausal symptoms and concerns about the potential impact of menopause on adherence to antiretroviral therapy (ART) and HIV viral load suppression. More recent data from the PRIME study showed that women who reported severe menopausal symptoms were more likely to be sub-optimally adherent to ART and to have sub-optimal clinic attendance.
A survey of general practitioners (GPs) in the UK found that less than half were confident in managing menopause in women living with HIV (in comparison to > 95% confidence in managing HIV-negative women). Despite nearly all believing that menopause in HIV-negative women should be managed in primary care, only 53% thought that menopause in women with HIV should be managed in primary care. They cited concerns around potential drug–drug interactions (DDIs), failing to recognize HIV-related illness and unknown risks of MHT in women with HIV.
The potential for interactions between ART and MHT, and the need to better understand menopause in women with HIV underscore the importance of developing experience in managing this growing cohort of women with unmet health needs. Consequently, in 2015 we established a monthly HIV menopause service overseen by a gynaecologist and an HIV physician. In this paper we describe the characteristics and clinical outcomes of women attending the HIV menopause clinic.
HIV Medicine. 2022;23(4):426-433. © 2022 Blackwell Publishing