Reflections on a Specialist HIV Menopause Service

Experiences of Managing Menopause in Women Living With HIV

Mimie Chirwa; Neda Taghinejadi; Gabrielle Macaulay; Sundhiya Mandalia; Claire Bellone; Nicholas Panay; Roberta Brum; Nneka Nwokolo

Disclosures

HIV Medicine. 2022;23(4):426-433. 

In This Article

Results

A total of 55 women attended the HIV menopause clinic over this 3.5 year period.

Patient Characteristics

The mean age at first attendance of all women attending the service was 49 years (SD = 6); 50% (n = 27) were black (African, Caribbean or other black background), and 18% were white British (Table 1).

Most women were referred by their HIV clinician, and referrals were received from across Greater London. Most women acquired HIV through heterosexual sex. Only 5% of patients acquired HIV through injecting drug use.

The median nadir CD4 count was 279 cells/μL and one-fifth of women had previously experienced an AIDS-defining condition, while 53% of women had been living with HIV for more than 10 years. All women were on ART; 93% had a viral load (VL) < 50 copies/mL at time of first clinic attendance and the median CD4 count at time of review was 678 cells/μL. All the women with VL > 50 copies/mL (n = 4) had documented evidence of difficulty taking ART as prescribed.

None of the women were current regular users of recreational drugs. However, four patients had evidence of previous, though not current, hepatitis C (HCV) coinfection. It is unclear whether clearance was spontaneous or the result of treatment. Smoking history was documented for 38 women; 10 were current and five were ex-smokers.

Comorbidities were common; nearly a quarter of women attending the clinic had been diagnosed with depression by their general practitioner, a psychologist or a psychiatrist. Risk factors for cardiovascular disease, including current smoking status, type 2 diabetes, hyperlipidaemia and obesity (body mass index, BMI > 30 kg/m2) were present in 42% of women (n = 23) attending the clinic. Two women had established cardiovascular disease and seven had a history of cancer. Forty-six (84%) women had a dual-energy X-ray absorptiometry (DEXA) scan, of whom 61% (n = 28) had evidence of osteopenia or osteoporosis (Figure 2).

Figure 2.

Bone Mineral Density

Over half (55%) had documented up-to-date cervical cytology; however, a significant proportion (40%) had no documentation of cervical cytology in the past year. It is notable that a third of women (n = 19) reviewed in this clinic had a history of abnormal cytology (CIN1–3) and two had previous cervical cancer; 62% of women were multiparous and 18% were nulliparous.

Most women (60%) were on tenofovir disoproxil fumarate (TDF) as a backbone drug in their ART regimen; 36% were on ART regimens based on nonnucleoside reverse transcriptase inhibitors (NNRTI), 35% on boosted protease inhibitors (PIs) and 27% on integrase strand transfer inhibitors (INSTIs). Six women (10%) were prescribed dual or mono ART. Dual therapy regimens included boosted darunavir with lamivudine, maraviroc or tenofovir disoproxil fumarate. All patients on monotherapy were prescribed boosted darunavir (Table 1).

Menopausal Symptoms

The most common presentation was with vasomotor symptoms (hot flushes, sweats and palpitations) (n = 46); however, most women had multiple symptoms at their initial assessment (Figure 3). Sixty-two per cent of women experienced changes in their menstrual cycle, 56% reported psychological problems (including labile mood, depression, anxiety, irritability and fatigue) and 29% had urogenital symptoms (vaginal dryness, urinary tract symptoms and dyspareunia).

Figure 3.

Menopause symptoms

Other clinical features included headaches (n = 17), sleeping difficulties (n = 16), musculoskeletal symptoms (n = 8), low sexual desire (n = 5) and difficulties trying to conceive (women who reported being unable to ever fall pregnant when trying to conceive or women with a diagnosis of POI who may have had previous pregnancy in the past but who were subsequently unable to fall pregnant) (n = 4).

The overall median duration of symptoms of all women before initial assessment in the HIV menopause clinic was 18 months [interquartile range (IQR): 11.5–39] and the mean duration was 31 months. The average age at clinic attendance of women with a menopause diagnosis (n = 24) was 52 years (Table 2). Their mean duration of menopause symptoms before attendance at the clinic was 28 months. Women diagnosed with POI had the longest average duration of symptoms prior to clinic review (52 months).

Three patients were investigated for other differential diagnoses before a diagnosis of menopause was made. These differential diagnoses included TB, cardiac arrhythmia and avascular necrosis of femur (AVN).

Early menopause or POI were reported in 22%. No association was seen between early menopause/POI and ethnicity, smoking history, AIDS diagnosis, nadir CD4 count, viral load, combination ART regimen, adherence, recreational drug use, cardiovascular risk/disease or previous cancer diagnosis (all p > 0.05).

Menopause Management

Overall, 73% (n = 40) of women were prescribed MHT; treatment was initiated in clinic for 34 women and continued for six patients (four of whom had MHT changed). Sixteen women declined treatment because of concerns about MHT risk (n = 8), absence of significant symptoms (n = 6) and conditions that precluded MHT initiation (n = 2). The two patients precluded from MHT initiation were undergoing medical investigation for a breast lump and peripheral vascular disease. Of those declining MHT, three patients opted for complementary/alternative therapies to control their menopausal symptoms.

Transdermal oestrogen (patch or gel) was prescribed in 92% of women on MHT. Of those women requiring endometrial protection, most (n = 31/35) opted for an oral progestogen rather than an intrauterine system, with most being prescribed natural progesterone (micronized progesterone) in preference to a synthetic progestogen. Supplemental testosterone gel or oestrogen vaginal cream was required for symptom management in 23% of women.

The median duration of MHT was 10 months (IQR: 3–27 months) at the time of data collection. Twenty-nine (73%) women seen at follow-up described improvement in symptoms; however, approximately half of these (n = 17) required an increase in their oestrogen dose for better symptom management, of whom 71% were on an interacting ART (eight on nevirapine, efavirenz or etravirine and four on ritonavir-boosted PI regimen). There was no association between overall response to MHT and ART regimen, menopause diagnosis or having a detectable viral load (all p > 0.05).

Adverse events were experienced in 35% (n = 14/40) of patients on MHT. This was mostly breakthrough bleeding (BTB) (n = 8). All women experiencing BTB were investigated with pelvic ultrasound, followed by hysteroscopy and biopsy if indicated. Hysteroscopy and biopsy were negative in all women who had completed investigations at the time of review. Of the women experiencing BTB on MHT, five were on interacting NNRTI regimens (nevirapine, efavirenz and etravirine), two were on INSTI regimens and one was on a ritonavir-boosted PI regimen. The NNRTI regimens in this group of women comprised nevirapine (n = 3), etravirine (n = 1) and rilpivirine (n = 1).

Other reported adverse events include breast lumps (one benign, two under investigation), allergy to transdermal preparations (n = 1), migraine with aura (n = 1) and sleep disturbance (n = 1). No reproductive malignancies, thromboembolic or other cardiovascular events were observed.

Modification of ART was necessary in five cases; in two women with newly diagnosed osteoporosis, TDF was discontinued because of its association with reduced BMD. Two women had possible DDIs with MHT that prevented optimization of symptom control, leading to a switch of ART; one switched from abacavir/lamivudine/atazanavir/ritonavir to abacavir/lamivudine/dolutegravir and the other from abacavir/lamivudine/nevirapine to tenofovir alafenamide/emtricitabine/dolutegravir.

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