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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 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 Cardiovascular disease Diabetes Osteoporosis Fertility Questions Menopause + HIV HIV or Menopause Menopause 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 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 + 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 + 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 Economic hardship Unemployment Low socioeconomic status More than 3 negative life events HIV-Infected Menopausal Care: Symptom Management HIV-Infected Non-HIV Infected 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 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 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 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 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 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 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 • • • • • • • 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 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