Menopause is a natural process that occurs when a woman’s ovaries stop producing eggs as the production of the female hormones (estrogen and progesterone) decline. Menopause can also occur if a woman’s ovaries are removed or injured.
Natural menopause is comprised of different stages. Perimenopause (also known as the menopausal transition) typically begins when a woman is in her mid-40s. During perimenopause, menstrual periods become irregular and eventually begin to taper off. A woman is considered to have reached menopause once menstrual periods have stopped for a full 12 months.
On average, American women reach menopause around the age of 51, but menopause can occur earlier or later, and some research suggests that women living with HIV experience menopause at an earlier age than women without HIV. This is particularly important given women represent a significant portion of people living with HIV.
Overlapping symptoms
Menopausal transition is a challenging phase for most women, but for women living with HIV, it can be particularly difficult. Vasomotor symptoms (VMS), also known as hot flashes or flushes and night sweats, are the most common symptom of menopause. VMS typically begin during perimenopause and have been shown to be more severe and frequent among women living with HIV. Further, VMS sometimes evoke memories of the symptoms associated with HIV that women living with the virus may have experienced when they were first diagnosed. VMS can lead to heightened anxiety and stress and compound the psychological burden that can accompany the menopausal transition. Other common symptoms of menopause include depression and mood changes, sleep disturbance, cognitive changes, weight gain and vaginal dryness.
The need for specialized care
Women living with HIV are at increased risk for conditions such as cardiovascular disease, osteoporosis (bone loss) and frailty due to HIV. Of concern, estrogen loss that occurs during menopause heightens the risk for the development of these conditions. This necessitates a tailored approach to healthcare that accounts for the unique challenges faced by women living with HIV. Education on menopause, regular preventative health screenings and a proactive approach to managing these risks and conditions are essential.
Current treatment options
Menopausal hormone therapy (estrogen with or without progesterone) is considered the most effective therapy for hot flashes and prevention of menopausal bone loss, but the safety and efficacy has not specifically been studied in women living with HIV. Non-hormonal alternatives such as selective serotonin reuptake inhibitors (often prescribed as anti-depressants) and a novel neurokinin 3 receptor antagonist (fezolinetant) are also approved by the U.S. Food and Drug Administration (FDA) for the treatment of menopausal hot flashes. These options are available by prescription only, and women should discuss them with their care providers to determine which therapy might be best for them.
A call for research and awareness
Despite the growing awareness of the challenges faced by menopausal women living with HIV, more research is needed. One area that requires urgent attention is the safety and efficacy of hormone therapy for menopausal women living with HIV. Current guidelines for the use of menopausal hormone therapy are based on data from women without HIV and may not be applicable to women living with HIV. To address this gap, the Advancing Clinical Therapeutics Globally (ACTG) study group has planned a study, Menopausal Hormone Therapy for Women Living with HIV (A5424 HoT). The study aims to evaluate the safety and efficacy of menopausal hormone therapy in women living with HIV and will provide much-needed data to inform future treatment guidelines. It is funded by the National Institute of Aging, along with the Division of AIDS and the authors of this article are principal investigators. Recruitment and enrollment for the HoT study will open in 2025.
Conclusion
Menopause in women living with HIV is a complex and multifaceted reproductive health phase that requires a comprehensive and interdisciplinary approach. By increasing awareness, tailoring healthcare strategies and expanding research efforts, women living with HIV can receive better support during this challenging midlife phase.
GO TO actgnetwork.org to check on enrollment openings and progress of the HoT study.
Sara Hurtado Bares, MD is an associate professor in the Division of Infectious Diseases at the University of Nebraska Medical Center.
Sara E. Looby, PhD, ANP-BC, FAAN, is a researcher at the Massachusetts General Hospital and an assistant professor of medicine at Harvard Medical School.
Michael T. Yin, MD, MS, is an associate professor of medicine and program director at the Columbia University. He is an active investigator in Women’s Interagency HIV Study and the Advancing Clinical Therapeutics Globally study group.