Substance use and psychotherapeutic medications: a likely contributor to menstrual disorders in women who are seropositive for human immunodeficiency virus

A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs

BACKGROUND

Domains of adequate menstrual health (MH) include access to water, sanitation, and hygiene (WASH). People who menstruate with social disadvantages-such as homelessness or drug injection practices-often face barriers to WASH access. However, validated instruments to measure MH are limited among marginalized populations, and available instruments involve lengthy surveys. We developed and evaluated psychometric properties of a novel 'MH WASH Domain Scale-12' among people who menstruate and who inject drugs in the Tijuana-San Diego region and identified correlates of MH access using this scale.

METHODS

We constructed a MH-scale based on access to twelve WASH-related items: (1) menstrual products, (2) body hygiene (bathing per week), (3) water sources for bathing, (4) improved, (5) non-shared, (6) available, (7) private, (8) nearby, (9) and safe sanitation facilities, (10) availability of soap, (11) water source for handwashing, and (12) handwashing facilities with soap/water. Variables were dichotomized and summed, with scores ranging from 0-12 points and higher scores indicating better MH access. We assessed the scale's reliability and construct and content validity using data from a binational cross-sectional study. The sample included people who inject drugs (PWID) who had ever menstruated in their lifetime and were 18+ during 2020-2021. MH-WASH items were described, and the scale was further used as an outcome variable to identify correlates.

RESULTS

Among 125 (124 cis-female and 1 trans-male) PWID that reported menstruating, our 'MH WASH Domain Scale-12' was reliable (Cronbach's alpha = 0.81, McDonald's Omega total = 0.83) and valid. We identified two sub-domains: Factor-1 included items describing 'WASH availability' and Factor-2 contained items related to 'WASH security'-encompassing physical and biological safety. Scale scores were significantly lower among participants experiencing unsheltered homelessness compared to participants experiencing sheltered homelessness or living in permanent housing.

CONCLUSION

We constructed and validated a novel and reliable scale to measure MH-related WASH access that can be used to assess MH among marginalized populations in English- and Spanish-speaking contexts. Using this scale we identified disparities in MH-WASH access among PWID and who menstruate in the US-Mexico border region.

Follicle-stimulating hormone in postmenopausal women living with HIV: a prevalence study

Objectives

We examined follicle‐stimulating hormone (FSH) levels in women living with HIV aged > 45 reporting ≥ 12 months’ amenorrhoea, and investigated correlation with menopausal symptoms.

Methods

A cross‐sectional substudy of 85 women from the Positive Transitions through the Menopause (PRIME) Study who reported irregular periods at entry into the PRIME Study and ≥ 12 months’ amenorrhoea at recruitment into this substudy. Serum FSH was supplemented with clinical data and menopausal symptom assessment. Serum FSH > 30 mIU/mL was defined as consistent with postmenopausal status. Associations between FSH and menopausal symptom severity were assessed using Pearson's correlation and the Kruskal–Wallis test.

Results

Median age was 53 years [interquartile range (IQR): 51–55]; all were on antiretroviral therapy, three‐quarters (n = 65) had a CD4 T‐cell count > 500 cells/μL and 91.8% (n = 78) had an HIV viral load (VL) < 50 copies/mL. Median FSH was 65.9 mIU/mL (IQR: 49.1–78.6). Only four women (4.7%) had FSH ≤ 30 mIU/mL; none reported smoking or drug use, all had CD4 T‐cell count ≥ 200 cells/μL, and one had viral load (VL) ≥ 50 copies/mL. Median body mass index (BMI) was elevated compared with women with FSH > 30 mIU/mL (40.8 vs. 30.5 kg/m²).

Over a quarter (28.2%) reported severe menopausal symptoms, with no correlation between FSH and severity of menopausal symptoms (p = 0.21), or hot flushes (p = 0.37).

Conclusions

Four women in this small substudy had low FSH despite being amenorrhoeic; all had BMI ≥ 35 kg/m². We found that 95% of women with HIV aged > 45 years reporting ≥ 12 months’ amenorrhoea had elevated FSH, suggesting that menopausal status can be ascertained from menstrual history alone in this group.

Contraceptive initiation after delivery among women with and without opioid use disorders: A retrospective cohort study in a statewide Medicaid population, 2005-2016

BACKGROUND

This study examined contraceptive initiation patterns in the 12 months following childbirth among women with opioid use disorder (OUD), women with non-opioid substance use disorders (SUDs), and women without SUDs.

METHODS

We conducted a retrospective cohort study using claims data from South Carolina Medicaid-enrolled women aged 15-44 who had singleton live birth between January 2005 and December 2016. Study outcomes were initiation of most or moderately effective (MME) contraceptive methods. Using multivariable and propensity score-weighted logistic regression, we analyzed the relationship between OUD and contraceptive initiation within 12 months after delivery.

RESULTS

We identified 71,283 live birth deliveries during the study period. In multivariable analysis, women with non-opioid SUDs and women without SUDs compared to women with OUD were more likely to initiate a MME method vs a least effective method or no method by 3 months (non-opioid SUDs: odds ratio [OR] = 1.32, 95 % confidence interval [CI] = 1.14-1.52; no SUDs: OR = 1.55, 95 % CI = 1.36-1.77) and 12 months (non-opioid SUD: OR = 1.23, 95 % CI = 1.06-1.42; no SUD: OR = 1.46, 95 % CI = 1.27-1.66) after delivery. With regards to the timing of initiation, women with non-opioid SUDs and women without SUDs were more likely than women with OUD to initiate a MME method vs a least effective method or no method after the immediate postpartum period through 3 months following delivery (non-opioid SUDs: OR = 1.41, 95 % CI = 1.18-1.68; no SUDs: OR = 1.87, 95 % CI = 1.59-2.21). We detected the similar patterns in analyses that used propensity score weighting.

CONCLUSION

OUD was associated with decreased likelihood of initiating a MME contraceptive method within 12 months after delivery.

Prolonged Amenorrhea and Low Hip Bone Mineral Density in Women Living With HIV-A Controlled Cross-sectional Study

BACKGROUND

Women living with HIV (WLWH) have higher rates of prolonged secondary amenorrhea (no flow for ≥1 year) than HIV-negative women. Both having amenorrhea and being HIV positive are associated with lower areal bone mineral density (BMD). However, their combined BMD effects remain unclear. Therefore, we investigated prolonged amenorrhea and BMD in WLWH and controls.

METHODS

This cross-sectional study enrolled WLWH and HIV-negative control women aged 19-68 years of similar backgrounds. We assessed BMD (Hologic; as age- and ethnicity-matched Z-scores) in the Children and women: AntiRetrovirals and Markers of Aging cohort. Participants were stratified by amenorrhea history defined as past/present lack of menses for ≥1 year at age 45 and younger and not because of surgery, breastfeeding, pregnancy, or hormonal contraception. Hip and spine Z-scores by amenorrhea/no amenorrhea used linear models with multivariable analysis for relationships within WLWH.

RESULTS

WLWH (N = 129) were similar to controls (N = 129) in age, body mass index, ethnicity, and substance use. Among WLWH, 21% experienced prolonged amenorrhea vs. 9% in controls. WLWH had significantly lower total hip (mean ± SD: -0.4 ± 0.9 vs. 0.3 ± 1.1; P < 0.001) and spine (-0.5 ± 1.3 vs. 0.2 ± 1.3; P = 0.001) Z-scores than controls. Amenorrhea was independently associated with hip (P = 0.01) but not spine (P = 0.94) BMD by multivariable linear regression. WLWH with amenorrhea had lower hip Z-scores (-0.8 ± 0.9) than those without (-0.3 ± 0.8; P = 0.01). They also had higher rates of substance use, smoking, opioid therapy, hepatitis C coinfection, and lower CD4 nadir.

CONCLUSIONS

WLWH had higher rates of prolonged amenorrhea and lower BMD than controls. WLWH with amenorrhea experienced lower hip BMD Z-scores than those without. Prolonged amenorrhea is an added osteoporosis risk in WLWH.

High prevalence of abnormal menstruation among women living with HIV in Canada

Objectives

To measure the prevalence and correlates of abnormal menstruation among women living with HIV (WLWH) in Canada.

Methods

We used cross-sectional questionnaire data from the community-based Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS), which enrolled WLWH aged ≥16 from British Columbia (BC), Ontario, and Quebec. For this analysis, we excluded women >45 years, who had primary amenorrhea, were pregnant, on hormonal contraception, or who reported history of endometrial cancer, last menstrual period >12 months ago, or premature ovarian failure. The primary outcome was abnormal menstruation (Yes vs No) based on responses to five questions about menstrual regularity, frequency, volume, duration, and intermenstrual bleeding in the six months prior to interview. An exploratory multivariable logistic regression analysis examined independent correlates of abnormal menstruation.

Results

Of 1422 women enrolled, 521 (37%) met eligibility criteria. Overall, 55.9% (95% CI:52%-60%) reported abnormal menstruation. In adjusted analyses, abnormal menstruation was associated with having a biologic sister/mother who entered menopause before age 40 (AOR 5.01, 95%CI 1.39–18.03), Hepatitis B co-infection (AOR 6.97, 95%CI 1.52–31.88), current smoking (AOR 1.69, 95%CI 1.55–3.41); and currently taking antiretroviral therapy (ART) (AOR 2.36, 95%CI 1.25–4.45) compared to being ART-naïve. Women in BC had higher adjusted odds of abnormal menstruation (AOR 2.95, 95%CI 1.61–5.39), relative to women in Ontario and Quebec.

Conclusions

Over half of WLWH in this analysis had abnormal menstruation. Correlates of abnormal menstruation include genetic, socio-behavioural factors (province of residence, smoking), Hepatitis B co-infection, and current ART use.

HIV and amenorrhea: a meta-analysis

OBJECTIVE

There is conflicting literature to support a link between HIV and amenorrhea. Here, we conduct a meta-analysis to summarize the results from landmark studies in this area and shed light on this important clinical association.

METHODS

Using a search of Ovid Medline and Embase, a total of 322 articles were screened for controlled matched observational studies of amenorrhea in premenopausal women living with HIV (WLWH). For inclusion, amenorrhea was defined as absence of menses for 3 months or longer. The meta-analysis used a random-effects model with an I2 calculated to assess heterogeneity.

RESULTS

Six studies from 1996 to 2010 were included in our analysis for a total of 8925 women (6570 WLWH). There was a significant association between HIV status and amenorrhea (OR 1.68, P value 0.0001) without evidence of heterogeneity (I2: 0.0%). In the majority of studies, there was no significant difference in substance use, smoking, or socioeconomic status between WLWH and controls. Additionally, in the majority of studies, amenorrhea in the setting of low BMI was significantly more frequent in WLWH than controls.

CONCLUSION

This meta-analysis provides a large population assessment of amenorrhea in HIV to suggest increased prevalence of menstrual disturbances in WLWH. It lends evidence suggestive that this relation is independent of substance use and socioeconomic status, but may be related to low BMI. Our findings reinforce the importance of routine assessment of reproductive health and time of last menstrual period as part of the health assessment of women, especially those living with HIV.

Longitudinal Changes in Body Composition by Dual-energy Radiograph Absorptiometry Among Perinatally HIV-infected and HIV-uninfected Youth: Increased Risk of Adiposity Among HIV-infected Female Youth

BACKGROUND

Combination antiretroviral therapy has allowed youth with perinatal HIV infection (PHIV+) to live into adulthood, but many youth may experience metabolic and body composition changes that predispose to greater cardiovascular disease (CVD) risk. This longitudinal study evaluated changes in body composition measured by dual-energy radiograph absorptiometry (DXA) in a cohort of PHIV+ youth compared with HIV- controls over a 7-year period.

METHODS

PHIV+ youth and HIV- controls were prospectively enrolled in a single-site study to assess nutrition and CVD risk. Anthropometrics and DXA scans were longitudinally obtained to assess percent body fat and regional fat distribution. Using general linear models, we analyzed differences in body composition and anthropometric measures by sex between PHIV+ youth and controls over time.

RESULTS

Two hundred thirty-five participants (156 PHIV+ and 79 HIV- controls) with at least 1 DXA performed since study enrollment were included for analysis. During the study period, 471 DXAs were obtained in the PHIV+ group and 95 in HIV- controls. PHIV+ females demonstrated greater increase in weight and body mass index over time compared with HIV- females, and significant increases in total percent body fat [estimate = 1.212 (95% confidence interval: 0.837-1.587) percent per year; P < 0.001) and percent trunk fat [1.3818 (95% confidence interval: 0.922-1.84); P < 0.001] compared with HIV- females and PHIV+ males.

CONCLUSIONS

PHIV+ females demonstrate an unfavorable change in fat redistribution and percent body fat over time that exceeds the pattern seen in PHIV+ males or HIV- females. Providers should have heightened awareness of body composition changes of PHIV+ females that may eventually lead to increased CVD risk.

Prolonged Amenorrhea and Resumption of Menses in Women with HIV

OBJECTIVE

To compare etiologies of prolonged amenorrhea in a cohort of HIV-infected women with a cohort of similar uninfected at-risk women.

MATERIALS AND METHODS

Women from the Women's Interagency HIV Study were seen every 6 months, and completed surveys including questions about their menstruation. Those who reported no vaginal bleeding for at least 1 year ("prolonged amenorrhea") with subsequent resumption of bleeding were compared with women in whom bleeding had stopped permanently ("menopause"). Characteristics associated with reversible prolonged amenorrhea were ascertained.

RESULTS

Of 828 women with prolonged amenorrhea, 37.6% had reversible amenorrhea and 62.4% never resumed menses. HIV-seropositive women with prolonged amenorrhea were significantly younger at cessation of menses than HIV-negative women (p < 0.0001). Of those with reversible prolonged amenorrhea, approximately half were taking medications associated with amenorrhea, including 95 (30.6%) hormonal contraception, 80 (25.7%) opiates/stimulants, 16 (5.1%) psychotropic medications, and 6 (1.9%) chemotherapy. HIV-seropositive women were less likely to have medications as a cause of amenorrhea than seronegative women (p = 0.02). In multivariable analysis, women with reversible prolonged amenorrhea of unknown etiology were younger (p < 0.0001), more often obese (p = 0.03), and less educated (p = 0.01) than those with permanent amenorrhea. Among HIV-seropositive women, markers of severe immunosuppression were not associated with prolonged amenorrhea.

CONCLUSION

Women with HIV infection have unexplained prolonged amenorrhea more often than at-risk seronegative women. This is especially common among obese, less-educated women. Prolonged amenorrhea in the HIV-seropositive women should be evaluated and not be presumed to be to the result of menopause.

Practice Bulletin No. 167: Gynecologic Care for Women and Adolescents With Human Immunodeficiency Virus

In the United States in 2013, there were an estimated 226,000 women and adolescents living with human immunodeficiency virus (HIV) infection (1). Women with HIV are living longer, healthier lives, so the need for routine and problem-focused gynecologic care has increased. The purpose of this document is to educate clinicians about basic health screening and care, family planning, prepregnancy care, and managing common gynecologic problems for women and adolescents who are infected with HIV. For information on screening guidelines, refer to the American College of Obstetricians and Gynecologists' Committee Opinion No. 596, Routine Human Immunodeficiency Virus Screening (2).

Hepatic Fibrosis Progression in HIV-Hepatitis C Virus Co-Infection--The Effect of Sex on Risk of Significant Fibrosis Measured by Aspartate-to-Platelet Ratio Index

BACKGROUND

In Hepatitis C virus (HCV) mono-infection, male sex is associated with faster liver fibrosis progression but the effects of sex have not been well studied in HIV-HCV co-infected patients. We examined the influence of sex on progression to significant liver fibrosis in HIV-HCV co-infected adults receiving antiretroviral therapy (ART) using the aspartate aminotransferase-to-platelet ratio index (APRI) as a surrogate biomarker of liver fibrosis.

METHODS

We evaluated 308 HIV infected, HCV RNA positive participants of a Canadian multicentre prospective cohort receiving antiretrovirals and without significant liver fibrosis or end-stage liver disease at baseline. We used multivariate discrete-time proportional hazards models to assess the effect of sex on time to significant fibrosis (APRI≥1.5) adjusting for baseline age, alcohol use, cigarette smoking, HCV duration, and APRI and time-updated CD4 count and HIV RNA.

RESULTS

Overall, 55 (18%) participants developed an APRI ≥ 1.5 over 544 person-years of at-risk follow-up time; 18 (21%) women (incidence rate (IR)=14.0/100 PY; 7.5-20.4) and 37 (17%) men (IR=8.9/100 PY; 6.0-11.8). Women had more favourable profiles with respect to traditional risk factors for liver disease progression (younger, shorter duration of HCV infection and less alcohol use). Despite this, female sex was associated with a greater than two-fold increased risk of fibrosis progression (adjusted hazard rate (HR) =2.23; 1.22-4.08).

CONCLUSIONS

HIV-HCV co-infected women receiving antiretroviral therapy were at significantly greater risk of progressing to liver fibrosis as measured by APRI compared with men. Enhanced efforts to engage and treat co-infected women for HCV are needed.

HIV infection and cardiovascular disease in women

Background

HIV infection is associated with increased risk of cardiovascular disease (CVD) in men. Whether HIV is an independent risk factor for CVD in women has not yet been established.

Methods and Results

We analyzed data from the Veterans Aging Cohort Study on 2187 women (32% HIV infected [HIV⁺]) who were free of CVD at baseline. Participants were followed from their first clinical encounter on or after April 01, 2003 until a CVD event, death, or the last follow‐up date (December 31, 2009). The primary outcome was CVD (acute myocardial infarction [AMI], unstable angina, ischemic stroke, and heart failure). CVD events were defined using clinical data, International Classification of Diseases, Ninth Revision, Clinical Modification codes, and/or death certificate data. We used Cox proportional hazards models to assess the association between HIV and incident CVD, adjusting for age, race/ethnicity, lipids, smoking, blood pressure, diabetes, renal disease, obesity, hepatitis C, and substance use/abuse. Median follow‐up time was 6.0 years. Mean age at baseline of HIV⁺ and HIV uninfected (HIV⁻) women was 44.0 versus 43.2 years (P<0.05). Median time to CVD event was 3.1 versus 3.7 years (P=0.11). There were 86 incident CVD events (53%, HIV⁺): AMI, 13%; unstable angina, 8%; ischemic stroke, 22%; and heart failure, 57%. Incident CVD/1000 person‐years was significantly higher among HIV⁺ (13.5; 95% confidence interval [CI]=10.1, 18.1) than HIV⁻ women (5.3; 95% CI=3.9, 7.3; P<0.001). HIV⁺ women had an increased risk of CVD, compared to HIV⁻ (hazard ratio=2.8; 95% CI=1.7, 4.6; P<0.001).

Conclusions

HIV is associated with an increased risk of CVD in women.

Predictors of pregnancy and changes in pregnancy incidence among HIV-positive women accessing HIV clinical care

OBJECTIVES

To describe predictors of pregnancy and changes in pregnancy incidence among HIV-positive women accessing HIV clinical care.

METHODS

Data were obtained through the linkage of two separate studies: the UK Collaborative HIV Cohort study (UK CHIC), a cohort of adults attending 13 large HIV clinics; and the National Study of HIV in Pregnancy and Childhood (NSHPC), a national surveillance study of HIV-positive pregnant women. Pregnancy incidence was measured using the proportion of women in UK CHIC with a pregnancy reported to NSHPC. Generalized estimating equations were used to identify predictors of pregnancy and assess changes in pregnancy incidence in 2000-2009.

RESULTS

The number of women accessing care at UK CHIC sites increased as did the number of pregnancies. Older women were less likely to have a pregnancy [adjusted relative rate (aRR) 0.44 per 10 year increment in age, [95% confidence interval (CI) (0.41-0.46)], P < 0.001] as were women with CD4 cell count less than 200 cells/μl compared with CD4 cell count 200-350 cells/μl [aRR 0.65 (0.55-0.77), P < 0.001] and women of white ethnicity compared with women of black African ethnicity [aRR 0.67 (0.57-0.80), P < 0.001]. The likelihood that women had a pregnancy increased over the study period [aRR 1.05 (1.03-1.07), P < 0.001). The rate of change did not significantly differ according to age group, antiretroviral therapy use, CD4 group or ethnicity.

CONCLUSION

The pregnancy rate among women accessing HIV clinical care increased in 2000-2009. HIV-positive women with, or planning, a pregnancy require a high level of care and this is likely to continue and increase as more women of older age have pregnancies.

Care of the human immunodeficiency virus-infected menopausal woman

More women than ever before are both human immunodeficiency virus infected and menopausal, because of increased survival and more frequent diagnosis in older women. Such a woman has the combined burden of her infection, its treatment, comorbid conditions, and aging. Thus, she is at risk for a variety of problems, such as disorders of bone mineral density and deficiencies in cognitive functioning. In addition to this, she experiences menopause in a unique fashion, with more symptoms and perhaps at an earlier age. The clinician caring for her must take a proactive approach to this multitude of factors that may affect her health and well-being.

Low levels of adherence to antiretroviral therapy in HIV-1-infected women with menstrual disorders

We evaluated the prevalence of menstrual disorders in HIV-1-infected women and explored the association between such disorders and adherence to antiretroviral therapy, sexual functioning, and depressive symptoms in a group of HIV-1-infected women aged younger than 46 years and on antiretroviral therapy. Participants were included in a cross-sectional survey between June 2005 and December 2006. Women provided information about their menstrual cycle and adherence in a single visit and responded to the Greene Climacteric Scale, the Massachusetts General Hospital Sexual Functioning Questionnaire and the Beck Depression Inventory. Women with and without menstrual disorders were compared using parametric and nonparametric tests. A multivariate stepwise logistic regression model was developed. The participants were 107 Caucasian women with a median (interquartile range [IQR]) age of 39 years (IQR, 36-42 years) and a median CD4 cell count of 483 cells/mm(3) (IQR, 332-679 cells/mm(3)). The viral load was below 50 copies per milliliter in 76.6% of the women. Sixty-four percent of the women had acquired HIV-1 infection through sexual intercourse. Menstrual disorders, observed in 32% of participants, were more frequent in women with detectable viral loads (p = 0.018). Women with menstrual disorders reported worse adherence (p = 0.005) and more sexual dysfunction (p < 0.05). Sixty-nine percent of the women who attributed their menstrual disorders to the use of antiretrovirals had inadequate adherence. Depressive symptoms were not observed. Vasomotor symptoms (p = 0.004), having a detectable viral load (p = 0.03) and adherence less than 95% (p = 0.02) were predictors of menstrual disorder. A third of the HIV-1-infected women assessed had menstrual disorders that impacted negatively on adherence to therapy and sexual function. The subjective attribution of these irregularities to antiretrovirals seems to affect medication intake, possibly favoring negative clinical consequences.

Buprenorphine and methadone treatment of opiate dependence during pregnancy: comparison of fetal growth and neonatal outcomes in two consecutive case series

AIM

To compare the effects of fetal buprenorphine and methadone exposure during maintenance treatment of pregnant heroin dependent subjects.

DESIGN AND SETTING

A population based comparison of consecutive, prospectively followed buprenorphine-exposed pregnancies in Stockholm County, Sweden, to retrospectively analyzed consecutive methadone-exposed pregnancies.

PARTICIPANTS

All 47 pregnancies in 39 women with opiate dependence and buprenorphine maintenance treatment 2001-2006, and all 35 methadone-exposed pregnancies (26 women) 1982-2006 in Stockholm County.

MEASUREMENTS

Intrauterine growth, birth outcome, malformations, neonatal adaptation, withdrawal syndrome and infant mortality.

FINDINGS

Buprenorphine-exposed pregnancies resulted in 47 uneventful live births (2 twin pairs), 1 stillbirth (for which no explanation was found) and 1 miscarriage. The birth weight of the infants was normal. Neonatal abstinence syndrome (NAS) occurred in 19 cases (40.4%), the majority mild in nature and only 7 (14.9%) needing withdrawal treatment. Compared to 35 infants born after intrauterine methadone exposure at the same hospital since 1982 (77.8% of them exhibiting NAS and 52.8% needing withdrawal treatment), there were significant advantages with buprenorphine treatment: birth weight was higher, due to longer gestation. Incidence of NAS of any intensity, as well as incidence of NAS that required pharmacological treatment was lower, while length of hospital stay was shorter. When buprenorphine treatment started pre-conception, NAS at any level was significantly less frequent than in subjects with post-conception initiated treatment (7/27, 26%; 12/20, 60%, respectively).

CONCLUSIONS

Data from this non-randomized comparison suggest that buprenorphine may offer advantages for treatment of opiate dependence during pregnancy.

HIV and menopause: a review

The use of highly active antiretroviral therapy (HAART) has resulted in dramatic reductions in morbidity and mortality of HIV infected individuals. With increasing life expectancy, a growing population of women will experience menopausal transitions while infected with HIV. Changes associated with menopause may affect HIV disease progression, and HIV-infected women may experience menopause in a different way from that of uninfected women. Age at natural menopause among non-HIV-infected white and Hispanic women is on the average 51 years, and that of African American women is 49 years. Several studies have shown that the mean age of menopause in HIV-infected women is 47-48 years. This is likely due to factors other than HIV infection that predict early menopause, such as drug use, smoking, and low socioeconomic status. It may be difficult to separate out HIV symptoms from menopausal symptoms. The additive effects of menopause, HIV infection, and HAART on changes involving bone, lipid, and glucose metabolism need further investigation. Likewise, there is a need for a better understanding of the prevalence and manifestations of depression among these women.

Special care issues of women living with HIV-AIDS

Many HIV-infected women are benefiting from highly active antiretroviral therapy and living longer. Their reproductive choices vary over the life cycle, and there is a need to understand the appropriate contraceptives for those not intending pregnancy. There are specific gynecologic issues relevant to HIV-infected women, such as genital tract infections, risk for cervical cancer, and menstrual irregularities. More women are expected to reach menopause. Health care providers should be aware of these unique needs of HIV-infected women.

Biologic markers of ovarian reserve and reproductive aging: application in a cohort study of HIV infection in women

OBJECTIVE

To compare Müllerian inhibiting substance (MIS) levels in serum obtained during the early follicular phase to those obtained randomly during the menstrual cycle. To determine whether HIV infection influences early follicular MIS levels, an early marker of ovarian aging.

DESIGN

A cross-sectional study.

SETTING

Women's Interagency HIV Study, a multicenter prospective study.

PATIENT(S)

Serum samples obtained from 263 (187 HIV infected and 76 uninfected) participants of the Women's Interagency HIV Study who reported menstrual bleeding during the preceding 6 months and who were not taking exogenous hormones.

INTERVENTION(S)

Early follicular (cycle days 2-5) MIS samples were compared with serum samples that had been obtained without regard to menstrual cycle phase. Comparison samples were obtained within 6 weeks before or within 3 to 6 months after the early follicular samples. Early follicular FSH, E(2), inhibin B, and MIS levels were also compared between the HIV infected and uninfected women.

MAIN OUTCOME MEASURE(S)

Correlation between early follicular MIS and prior and subsequent samples. Comparison of serum markers of ovarian reserve between HIV positive and negative women.

RESULT(S)

The MIS values from early follicular and other random cycle phases were highly correlated with each other (r > 0.93). In multivariate analysis, increased age and FSH level and lower inhibin B levels were associated with lower MIS level; MIS values did not vary by HIV serostatus.

CONCLUSION(S)

Without regard to cycle phase, MIS was similar during early follicular phase and highly correlated with early follicular FSH and inhibin B in women with and without HIV. Measurement of serum MIS offers a simplified method of determining ovarian reserve using specimens obtained without menstrual phase timing. Furthermore, using biologic measures of reproductive aging, we found no evidence that HIV infection influences ovarian aging.

Methadone in pregnancy: treatment retention and neonatal outcomes

AIM

To examine the association between retention in methadone treatment during pregnancy and key neonatal outcomes.

DESIGN

Client data from the New South Wales Pharmaceutical Drugs of Addiction System was linked to birth information from the NSW Midwives Data Collection and the NSW Inpatient Statistics Collection from 1992 to 2002.

MEASUREMENTS

Obstetric and perinatal characteristics of women who were retained continuously on methadone maintenance throughout their pregnancy were compared to those who entered late in their pregnancies (less than 6 months prior to birth) and those whose last treatment episode ended at least 1 year prior to birth.

FINDINGS

There were 2993 births to women recorded as being on methadone at delivery, increasing from 62 in 1992 to 459 births in 2002. Compared to mothers who were maintained continuously on methadone throughout their pregnancy, those who entered treatment late also presented later to antenatal services, were more likely to arrive at hospital for delivery unbooked, were more often unmarried, indigenous and smoked more heavily. A higher proportion of neonates born to late entrants were born at less than 37 weeks gestation and were admitted to special care nursery more often.

CONCLUSION

Continuous methadone treatment during pregnancy is associated with earlier antenatal care and improved neonatal outcomes. Innovative techniques for early engagement in methadone treatment by pregnant heroin using women or those planning to become pregnant should be identified and implemented.

Effects of human immunodeficiency virus on protracted amenorrhea and ovarian dysfunction

OBJECTIVE

To characterize ovarian failure and prolonged amenorrhea from other causes in women who are both human immunodeficiency virus (HIV) seropositive and seronegative.

METHODS

This was a cohort study nested in the Women's Interagency HIV Study, a multicenter U.S. study of HIV infection in women. Prolonged amenorrhea was defined as no vaginal bleeding for at least 1 year. A serum follicle stimulating hormone more than 25 milli-International Units/mL and prolonged amenorrhea were used to define ovarian failure. Logistic regressions, chi2, and t tests were performed to estimate relationships between HIV-infection and cofactors with both ovarian failure and amenorrhea from other causes.

RESULTS

Results were available for 1,431 women (1,139 HIV seropositive and 292 seronegative). More than one half of the HIV positive women with prolonged amenorrhea of at least 1 year did not have ovarian failure. When adjusted for age, HIV seropositive women were about three times more likely than seronegative women to have prolonged amenorrhea without ovarian failure. Body mass index, serum albumin, and parity were all negatively associated with ovarian failure in HIV seropositive women.

CONCLUSION

HIV serostatus is associated with prolonged amenorrhea. It is difficult to ascertain whether the cause of prolonged amenorrhea is ovarian in HIV-infected women without additional testing.

LEVEL OF EVIDENCE

II-2.

The experience of physical symptoms among women living with HIV

As the number of women living with HIV and AIDS increases, so does survival time for individuals living with this chronic condition. Symptom existence, intensity, and bothersomeness greatly affect quality of life in women living with HIV and AIDS. Symptoms experienced by women living with HIV include symptoms related to HIV infection itself, those related to opportunistic infections, and those related to medications and treatments. Symptoms experienced by women include those common to both genders and those specific to females. The presence and intensity of symptoms varies with progression of the disease and with deteriorating status of HIV disease indicators. While research is limited on this topic, some research on the general symptom experience of women and on symptoms specific to or common among women has been done. Extended life expectancy among women with HIV increases the importance of nursing care focused on symptom assessment and symptom management. This article reviews research on symptoms commonly experienced by women living with HIV and presents implications for the care of women experiencing distressing symptoms.

Effects of HIV Infection and Its Treatment on Self-Reported Menstrual Abnormalities in Women

OBJECTIVE

To describe menstrual abnormalities among women with HIV.

METHODS

Women in a multicenter prospective cohort study of HIV natural history reported menstrual abnormalities every 6-months between October 1994 and September 2002. Logistic regression and Cox proportional-hazards models were applied.

RESULTS

The prevalence and incidence of menstrual abnormalities were <20%. HIV serostatus was not associated with prevalent menstrual abnormalities, but in HIV-seropositive women, higher CD4 counts were associated with fewer problems: compared with women with CD4 counts <200/mm3, in women with counts 200-500/mm3, odds ratio (OR) for amenorrhea was 0.55, p = 0.02, and for oligomenorrhea was 0.54, p = 0.0003; for women with counts >500/mm3, OR for amenorrhea was 0.67, p = 0.14, and for oligomenorrhea was 0.55, p = 0.001. HIV serostatus was not associated with incident abnormalities. Highly active anti-retroviral therapy (HAART) use was not associated with prevalent abnormalities, but both HAART use and higher CD4 counts were linked to lower rates of incident menstrual problems.

CONCLUSIONS

Compared with seronegative women, HIV-seropositive women are at increased risk for some menstrual changes, although the absolute frequency of most abnormalities is low. Higher CD4 counts and HAART protect against incident abnormalities.

Age of menopause and menopausal symptoms in HIV-infected women

The objective of this study was to examine the median age of menopause, factors associated with postmenopausal status, and the prevalence of menopausal symptoms in HIV-infected women. We surveyed 120 HIV-infected women between 40 and 57 years old who attended an inner city infectious diseases clinic. Ninety-five percent of the women surveyed were African American and almost half of the women (44%) had used methadone, heroin, cocaine, marijuana, or a combination of these drugs within the past 6 months. Eighty-seven percent had smoked cigarettes at least some time during their life and 45% drank alcohol between the ages of 40 and 49 years old. Thirty women were postmenopausal (having no menstrual periods in the previous 12 consecutive months), 31 were perimenopausal (having 1-11 periods within the previous 12 months), and 59 were premenopausal (having 12 or more periods within the previous 12 months). The median age of menopause was 50 years old (95% confidence interval = 49, 53). In a multivariate model, methadone use within the past 6 months was associated with postmenopausal status. We did not find an association between postmenopausal status and body mass index, number of pregnancies, CD4 cell counts, HIV viral load, individual and grouped antiretroviral therapies, cigarette smoking, and current or past oral contraceptive use. In multivariate analysis, postmenopausal status was associated with hot flashes and cocaine use was associated with vaginal dryness.

HIV infection, drug use, and onset of natural menopause

OBJECTIVE

To study the relationship of HIV infection and drug use with the onset of natural menopause.

METHODS

Our analyses used the World Health Organization's definition of menopause (i.e., the date of the last menstrual period is confirmed after 12 months of amenorrhea) and baseline data from a prospective study. Semiannual interviews were conducted. Levels of HIV antibody and CD4+ cell counts were obtained. Menopause was identified at baseline or during 12 months of follow-up. Women ingesting reproductive hormones were excluded. Logistic regression analyses were used to assess factors associated with menopause.

RESULTS

Of 571 women, 53% were HIV infected, and 52% had used heroin or cocaine in the previous 5 years. The median age was 43 years (interquartile range [IQR], 40-46 years); 48.9% of the women were black, 40.4% were Hispanic, and 10.7% were white. The median body mass index was 29.1 kg/m2, and 90.4% of participants were current or former cigarette smokers. Menopause was identified in 102 women: 62 HIV-infected women (median age, 46 years; interquartile range [IQR], 39-49 years) and 40 uninfected women (median age, 47 years; IQR, 44.5-48 years). Factors independently associated with menopause included HIV infection (adjusted odds ratio [OR], 1.73; 95% confidence interval [CI], 1.075-2.795), drug use (adjusted OR, 2.633; 95% CI, 1.610-4.308), and physical activity (adjusted OR, 0.895; 95% CI, 0.844-0.950). Among HIV-infected women, factors independently associated with menopause included CD4+ cell counts of >500 cells/mm3 (adjusted OR, 0.191; 95% CI, 0.076-0.4848) and 200-500 cells/mm3 (adjusted OR, 0.356; 95% CI, 0.147-0.813).

CONCLUSION

Our study shows that HIV infection and immunosuppression are associated with an earlier age at the onset of menopause. Whether early onset of menopause in HIV-infected women increases their risk of osteoporosis and heart disease requires further study.

Menstrual cycle length during methadone maintenance

AIMS

While the menstrual disruption of heroin has been demonstrated, there are few published data concerning methadone maintenance and menstrual function. This study was conducted to evaluate whether cycle length was more regular during methadone maintenance.

SETTINGS

An out-patient research treatment program in Baltimore, Maryland, USA.

PARTICIPANTS

A total of 191 heroin and cocaine-using women from two clinical trials, lasting 25-29 weeks; each woman was maintained on 70-100 mg of methadone.

MEASUREMENTS

Start/end dates of each menses were collected.

DESIGN

Menstrual patterns were classified as regular, irregular, transient amenorrhea, persistent amenorrhea or cycle restart. Repeated-measures regression modeling determined correlates of cycle length and predictors of long cycles (> 40 days) and short cycles (< 20 days). Bleeding episodes were defined as 1 or more bleeding days, bound by at least 2 non-bleeding days. Correlates/predictors examined were body mass index, drug use, methadone dose and race.

FINDINGS

In the 133 women for whom menstrual patterns could be determined, cycle-length irregularity was common: irregular, 62 (46.7%); regular, 37 (27.8%); cycle restart, 16 (12%); persistent amenorrhea, 11 (8.3%); transient amenorrhea, seven (5.3%). Each additional week on methadone maintenance was associated with decreased risk of long (OR = 0.96, P < 0.01 and short (OR = 0.92, P < 0.01) cycles. Of 27 women with secondary amenorrhea pre-study, 16 (59%) restarted menses. Positivity for opioids or cocaine was not significantly associated with short or long cycles.

CONCLUSIONS

Cycle length begins to normalize during methadone maintenance. Menses resumption may occur. Methadone maintenance, despite interfering with menstrual function in an absolute sense, may interfere less than illicit heroin abuse.