Download HIV and Menopause - CHOICES

Menopause and HIV: 101
Nikole D. Gettings, MSN, CNM
Director of Clinical Services
CHOICES
[email protected]
901-274-3550
Objectives
 Define clinical characteristics of perimenopause,
menopause and post-menopause, as well as other
causes of amenorrhea or ovarian failure
 Identify common patient reported menopausal
symptoms in HIV-infected population
 Identify health risks associated with menopause and
the impact of of HIV-infection and/or HIVmanagement on these health risks
 Identify resources for clinical guidance on the impact
of HIV-infection and/or HIV management on
symptoms and management of symptoms in peri/post-menopausal HIV-infected population
Menopause Statistics
 40 million women in
the next decade
 Women’s life
expectancy: 81.7
 Tripling of women
over age 50 in last
100 years
Menopause
 Retrospective: 12
consecutive months
of amenorrhea, not
caused by surgery
 W.H.O.
 correlated FSH levels
>25 or 35 MIU/ML
 No longer fertile
 No longer able to
release eggs
Hypothalmus-Pituitary-Brain
Axis
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Brain:
 Body Temperature
 Memory loss
 Reproductive hormones
Bone
 Mineral density
Breast
 Puberty
 Lactation
 Cancer
Heart and Liver
 Cholesterol
 Build up of Plaque
Ovary
 Maturation of follicles
Uterus
 Maturation
 Endometrial thickening
 Cancer
Vagina
 Maturation
 Lubrication
Perimenopause
 The Stages of
Reproductive Aging
Workshop (STRAW):
variation in menstrual
cycle length in a woman
with elevated FSH
 3 or more consecutive
months of amenorrhea in
a year, but less than 11
 Fluctuation in
“reproductive hormones”
Ovarian Failure
 Follicle depletion
(Permanent)
 Chromosomal
abnormality: Turner’s
syndrome, fragile X
 Toxins: Chemotherapy,
medications, cigarette
smoke, chemicals,
pesticides
 Follicle Dysfunction
(Reversible)
 Extremely low BMI (>18)
 Thyroid disorders
 Immune system disorders
Pregnancy/Pregnancy Loss
Most common
period of life to
experience an
unexpected,
unplanned
pregnancy
Phases of Perimenopause
Common Symptoms
of Perimenopause
flashes/Night Sweats:
Vasomotor
Urinary incontinence
Sleeping disorders
Sexual dysfunction
Depression
Anxiety
Labile mood
Memory loss
Fatigue
Headache
Joint pains
Weight gain
Postmenopausal Health
Effects
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Cardiovascular disease
Diabetes
Osteoporosis
Fertility
Questions
Menopause + HIV
HIV or Menopause
Menopause
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Hot Flashes
Night sweats
Mood liability
Vaginal dryness
Sleep disturbances
Memory loss
depression
Signs of HIV +
 lack of energy or fatigue
 weight loss
 frequent low-grade
fevers and night sweats
 frequent yeast infections
(in the mouth)
 skin rashes or flaky skin
that is hard to heal
 short-term memory loss
HIV Statistics (2007)
Research Topics: HIV and
Menopause
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Age at menopause
Menopausal Symptoms
Reproductive Hormones
Cognitive Function
Bone mineral density
Lipid metabolism
Glucose metabolism
Impact of HAART on CD-4 and Viral Loads
Imai, K., et al (2013)
Age of Menopause: 46-50
Average age 2-3 years younger than historical studies on White,
middle class
Early Age of Menopause
Early Menopause
 Cigarette smoking
 Low socioeconomic
markers
 Low level of education
 Unemployment
 African American
 Psychological stress
 Heroin/cocaine use
 Physical inactivity
HIV +
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70% of HIV positive women
smoke cigarettes
HIV affects lower socioeconomic
people disproportionately
Unemployment disproportionately
affects HIV +
In 2006, the rate of new HIV
infection for black women was
nearly 15 times as high as that of
white women and nearly 4 times
that of Hispanic/Latina women.
Reports of high prevalence of
drug use among HIV +
Calvet, G.; Grinnsztejn, BGJ, Quintana MSB; et al (2014). Predictors of early menopause in HIV-infected
women: a prospective cohort study. American Journal of Obstetrics & Gynecology. 212:1.e1-1.e13
Menopausal Symptom Report
in HIV +
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Attitudes toward menopause
Increased report of hot flashes
Increased report of vaginal dryness
Earlier report of symptoms
Lui-Filho, et al. (2013)
Most Menopause
Symptoms
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Economic hardship
Unemployment
Low socioeconomic status
More than 3 negative life events
HIV-Infected Menopausal Care:
Symptom Management
HIV-Infected
Non-HIV Infected
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HRT*
Oxybutynin ER*
SSRI: Monitor/Caution
Gabapentin: Monitor/Caution
Omega Fish Oils
Exercise
Yoga
Acupuncture
Herbal Remedies: NO
HRT
Oxybutynin ER
SSRI
Gabapentin
Omega Fish Oils
Exercise
Yoga
Acupuncture
Herbal Remedies: ? benefit
McPheeters, C.; Gregg, J. (2013). Treatment options for hot flashes in the HIV-Positive
menopausal patient. The Journal for Nurse Practitioners. 9(3): 166-171
Cognitive Function and
HIV-Infection
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Depression
Anxiety
Low education
Baseline mental or personality abnormalities
HIV associated Dementia: low CD4,
anaemia, low BMI, age, injection drug use,
female
 Access to HAART
Cognitive Function
 Consensus:
Menopause is not
consistently
associated with
memory loss,
Hormone
replacement therapy
(HRT) does not
improve
HIV-Infected Menopausal Care:
Cognitive Function
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Social Engagement
Intellectual Stimulation: Games, Puzzles
Meaningful work/volunteer
Community and Family Roles
BMD and HIV +
 Increased prevalence of
low bone mineral density
 Increased osteopenia
 Increased incidence of
Osteoporosis
 Fractures?
David, A.; Kulkarni, M.; Borkar, A.; et al. (2014). Prevalence of low bone mineral density among HIV patients on long-term
suppressive antiretroviral therapy in resource limited setting of western India. Abstracts of the HIV Drug Therapy Glasgow
Congress 2014. Journal of the International AIDS Society. 17(Suppl 3):19567
HIV-Infected Menopausal Care:
Bone Mineral Density
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Resistance Exercise
Vitamin D Supplementation
Calcium Supplementation
Early ART: lower baseline CD4 prior to
(HA)ART: low BMD
David, A.; Kulkarni, M.; Borkar, A.; et al. (2014). Prevalence of low bone mineral density among HIV patients on long-term
suppressive antiretroviral therapy in resource limited setting of western India. Abstracts of the HIV Drug Therapy Glasgow
Congress 2014. Journal of the International AIDS Society. 17(Suppl 3):19567
Lipid Metabolism/Glucose
Metabolism
Lipid/Glucose
Abnormalities
Lipid Metabolism/Glucose
Metabolism
HIV-Infected Menopausal Care:
Lipid and Glucose Metabolism
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Weight Control
Cardio Exercise
Omega 3 Fatty Acids/Fish Oil
Screening for HTN and DM
Treatment with monitoring for adequate
control of HTN and/or DM when indicated
HIV-Infected Menopausal Care:
Reproductive Health Care
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Contraception
STI Screening and treatment if indicated
Healthy Sexuality
PAP Smears/Cervical Health
Breast Mammography
Baldwin, M.; Jensen, T.; (2013). Contraception during the perimenopause. Maturitas, 76:235-242;
Kim, SC, et al. (2013). Effect of Highly Active Antiretroviral Therapy (HAART) and Menopause on Risk of
Progression of Cervical Dysplasia in Human Immune-Deficiency Virus-(HIV-) Infected Women. Infectious
Diseases in Obstetrics and Gynecology. http://dx.doi.org/10.1155/2013/784718
Taylor, T.; Weedon, J.; Golub, E.; et al. (2014) Longitudinal trends in sexual behaviors with advancing age and
menopause among women with and without HIV-1 Infection. AIDS Behavior. DOI: 10.1007/s10461-014-0901-1
PostMenopausal Health
Risks
Postmenopause
 Cardiovascular disease
 Diabetes
 osteoporosis
Postmenopause + HIV + HAART
 Dyslipidemia
 Insulin resistance
 osteopenia
HIV-Infected and
Menopause: Clinical Care
Resources
 The Well Project (Updated
August 2014). Menopause
and HIV. Accessed online at
http://www.thewellproject.org/
hiv-information/menopauseand-hiv
 Project Inform (January
2013). HIV and older age.
Wise Words; 10:1-8.
Accessed online at
http://www.thebody.com/conte
nt/art61732.html
 The Boston Women’s Health
Book Collective, Our Bodies,
Ourselves.
Advice: HIV-Infection and
Menopause
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Stay active
Maintain healthy weight
Hormone replacement therapy
for short term symptom
management
Eat a balanced diet
Routine health screenings for
cervical cancer, breast cancer,
cholesterol, blood pressure
Calcium and Vit D
Supplementation
Stay engaged
Long-term, stable partner
No ETOH
Best Advice: Have a
Healthy Mom
Case Study # 3: Is
this Menopause
Janelle
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47 yo AA female
Irregular bleeding
No vaginal bleeding x 6 months
“Like a regular period”
August/September
October: sudden onset of heavy
bleeding x 2 days, then stopped
Currently week prior to
Thanksgiving: no bleeding so
far
Other symptoms: having night
sweats
Case Study # 3: Is
this Menopause
Janelle
PMH
Medications
Family History
Social History
Sexual Health
History
Case Study # 3: Is
this Menopause
Janelle
Bleeding Assessment
• A) Dysfunctional
Uterine Bleeding
• B) Menopause
• C)Pregnancy/Loss
• D)Perimenopause
Case Study # 3: Is
this Menopause
Janelle
What would be a
treatment option for
Janelle’s hot
flashes/night
sweats?
• A) SSRI
• B) Acupuncture
• C) Yoga
• D) HRT
Case Study # 3: Is
this Menopause
Janelle
When you counsel
Janelle re: expectations
of how long her irregular
bleeding will last, which
is the most likely?
• A) 6 months
• B) 1-2 years
• C) 3-5 years
• D) For the rest of her
life
Case Study # 3: Is
this Menopause
Janelle
Which treatment options
for Janelle’s episodes of
heavy bleeding does she
have the LEAST
contraindication?
• A) Paragard IUD
• B) Mirena IUD
• C) Lysteda
• D) Ibuprofen prn
Case Study # 3: Is
this Menopause
Janelle
Pearl:
“The healthcare
professionals
responsible for
treating retroviruses
often neglect to treat
menopausal signs
and symptoms”
Lui-Filho, et al (2013)
References
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ACOG (2010). Practice bulletin number 117: Gynecologic care for women with human
immunodeficiency virus. Obstetrics & Gynecology; 116(6): 1492-1509.
Arnsten, J., et al. (2006). HIV infection and bone mineral density in middle-aged women. Clinical
Infectious Diseases; 42: 1014-20.
The Boston Women’s Health Book Collective, Our Bodies, Ourselves. 2005 ed. Simon & Schuster,
NY, NY.
Conde, D., et al. (2009). HIV, reproductive aging, and health implications in women: a literature
review. Menopause: The Journal of The North American Menopause Society; 16(1): 199-213.
Fan, M., et al. (2008). HIV and the menopause. Menopause International; 14: 163-68.
Hartel, D., et al. (2008). Attitudes toward menopause in HIV-infected and at-risk women. Clinical
Interventions in Aging; 3(3): 561-66.
Kamemoto, L. (2003). Hormones, Menopause, and HIV infection. Menopause Management; 8-12.
Available online at: http://www.menopausemgmt.com/issues/12-05/Kamemoto.pdf
Milunka, E., Wang, C., and Cu-Uvin, S. (2007). HIV and menopause: A review. Journal of Women’s
Health; 16(10): 1402-11.
Perez, J. and Moore, R. (2003). Greater effect of highly active antiretroviral therapy on survival in
people aged > 50 years compared with younger people in an urban observational cohort. Clinical
Infectious Diseases; 36: 212-8.
Project Inform (2002). HIV and older age. Wise Words; 10:1-8. Accessed online at
http://www.thebody.com/content/art5137.html
Santoro, N., et al. (2009). Women and HIV infection: The makings of a midlife crisis. Maturitas; 64(3):
160-64. Available online at
Schoenbaum, E., et al. (2005). HIV infection, drug use, and onset of natural menopause. Clinical
Infectious Diseases; 41:1517-24.
The Well Project (Updated April 2011). Menopause and HIV. Accessed online at
http://www.thewellproject.org/en_US/Womens_Center/Menopause.jsp