Impact of street drug use, HIV infection, and highly active antiretroviral therapy on reproductive hormones in middle-aged women

Collection of menopause data in studies of women living with HIV: A systematic literature review

OBJECTIVES

An increasing number of women living with HIV are transitioning through midlife and menopause. Women living with HIV may experience earlier menopause and a higher symptom burden than women without HIV, but more evidence is needed. Data collection on menopause in women living with HIV is scarce and often not standardized. We sought to assess how menopause data are collected in cohorts and studies of women living with HIV.

METHODS

This was a literature review conducted within the PubMed database. We included original studies and cohorts assessing menopause and/or menopausal symptoms in women living with HIV. Study characteristics and menopause data collection, including the definition of menopause, symptom assessment tools, and measurement of biomedical parameters, were noted and summarized systematically in data tables.

RESULTS

We included 40 articles describing 37 separate studies published between 2000 and 2023; 27 of these were conducted in high-income countries, the majority in the USA (n = 16). Ten studies were from low- and middle-income countries; four of these were conducted in Brazil. In 20 studies, menopause was defined according to the World Health Organization's definition of over 12 months of amenorrhea. Twelve studies used the Menopause Rating Scale to characterize menopausal symptoms, five studies used other specified symptom assessment tools, and 12 studies used a study-specific tool.

CONCLUSIONS

Menopause data collection in women living with HIV is heterogeneous. We propose that standardized tools should be used to enable comparisons between studies and countries, thereby improving the quality of research and clinical treatment. Further research into the validity of menopausal symptom scoring tools is warranted.

Ageing and older people who use illicit opioids, cocaine or methamphetamine: a scoping review and literature map

AIMS

To provide an overview of research literature on ageing and older people who use illicit opioids and stimulants by documenting the conceptual frameworks used and content areas that have been investigated.

METHODS

We conducted a scoping review of literature relating to ageing and older people who use illicit stimulants and opioids, defining 'older' as 40 years and above. Primary studies, secondary studies and editorials were included. Searches were conducted in PubMed and Embase in July 2020 and March 2021; the Cochrane library was searched in November 2021. Charted data included methodological details, any conceptual frameworks explicitly applied by authors and the content areas that were the focus of the publication. We developed a hierarchy of content areas and mapped this to provide a visual guide to the research area.

RESULTS

Of the 164 publications included in this review, only 16 explicitly applied a conceptual framework. Seven core content areas were identified, with most publications contributing to multiple content areas: acknowledgement of drug use among older people (n = 64), health status (n = 129), health services (n = 109), drug use practices and patterns (n = 84), social environments (n = 74), the criminal legal system (n = 28) and quality of life (n = 15).

CONCLUSIONS

The literature regarding older people who use illicit drugs remains under-theorized. Conceptual frameworks are rarely applied and few have been purposely adapted to this population. Health status and health services access and use are among the most frequently researched topics in this area.

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.

Health Characteristics Associated With Hot Flashes in Women With HIV During Menopause: An Integrative Review

Hot flashes (HFs) are a prominent symptom of menopause known to unfavorably influence mood, sleep, and quality of life. More women living with HIV are entering menopause and may experience a greater prevalence of HFs and more severe HFs compared with uninfected women. This integrative review evaluated existing evidence on potential health characteristics associated with HFs in women living with HIV during menopause. A search strategy was conducted within 6 databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided the review, and the Johns Hopkins Nursing Evidence-Based Practice model was used to evaluate methodological quality and appraisal of the evidence. Five articles met the review eligibility criteria. Three content categories emerged from the key findings of the 5 articles: HIV-specific characteristics, mental health and cognitive characteristics, and quality of life and social characteristics. Implications for research and clinical care were identified.

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.

Menstrual Cycle Changes as Women Approach the Final Menses: What Matters?

Increased variability in menstrual cycle length marks the onset of the menopausal transition, with the likelihood of long cycles increasing as women approach menopause. This article describes the STRAW+10 bleeding criteria for recognizing onset of the early and late menopausal transition, as well as the specific bleeding changes a woman may experience during this life stage, including how women's bleeding experiences differ. The high probability of episodes of excessive and prolonged bleeding as women approach their final menstrual period is documented, as is the continuing probability of ovulation as women reach their final menstrual period.

The impact of the menopause transition on the health and wellbeing of women living with HIV: A narrative review

Improvements in survival due to advances in antiretroviral therapy (ART) have led to a shift in the age distribution of those receiving HIV care, with increasing numbers of women living with HIV (WLHIV) reaching menopausal age. We present a narrative literature review of 26 studies exploring the menopause transition in WLHIV, focusing on: (1) natural history (2) symptomatology and management, and (3) immunologic and virologic effects. Data are conflicting on the association between HIV and earlier age at menopause, and the role of HIV-specific factors such as HIV viral load and CD4 count. There are some data to suggest that WLHIV experience more vasomotor and psychological symptoms during the menopause than HIV-negative women, and that uptake of hormone replacement therapy by WLHIV is comparatively low. There is no evidence that menopause affects either CD4 count or response to ART, although there may be increased immune activation in older WLHIV. We conclude that menopause in WLHIV is a neglected area of study. Specific information gaps include qualitative studies on experiences of reproductive ageing; data on the impact of the menopause on women's quality of life and ability to adhere to health-sustaining behaviors; as well as studies investigating the safety and efficacy of pharmacological and psychosocial interventions. There is likely to be a burden of unmet health need among this growing population, and better data are required to inform optimal provision of care, supporting WLHIV to maintain their health and wellbeing into their post-reproductive years.

Gonadotropin and sex steroid levels in HIV-infected premenopausal women and their association with subclinical atherosclerosis in HIV-infected and -uninfected women in the women's interagency HIV study (WIHS)

BACKGROUND

HIV-infected women may experience prolonged amenorrhea, suggesting altered gonadotropin and sex hormone levels. However, the impact of these endocrine disruptions on atherosclerosis has not been evaluated in women living with, or at risk for, HIV infection. We investigated the association of sex hormone and gonadotropin concentrations with subclinical atherosclerosis in HIV-infected and -uninfected premenopausal women in the Women's Interagency HIV Study.

METHODS

Using B-mode ultrasound, the common carotid artery intima-media thickness and distensibility were measured once. Cycle-specific FSH, total estradiol (E2), and inhibin-B concentrations were measured in 584 (414 HIV infected, 170 HIV uninfected) women. Random concentrations of total T, dehydroepiandrosterone sulphate, and SHBG were measured in 1094 (771 HIV infected, 323 HIV uninfected) women. The endocrine analytes were measured at or before the ultrasound visit. Sex hormones, FSH, and SHBG concentrations were compared between HIV-infected and -uninfected women using nonparametric testing. Linear regression models were used to evaluate the association of sex hormones, FSH, and SHBG with carotid artery intima-media thickness and distensibility adjusted for confounders. Separate analyses were conducted by HIV status.

RESULTS

Compared with HIV-uninfected women, E2, T, and dehydroepiandrosterone sulphate concentrations were significantly lower and SHBG was higher in HIV-infected women. Adjusted for the confounders, T was significantly positively associated with distensibility (β-estimate = .04, P = .0005) among HIV-infected women, and the magnitude of association did not differ by CD4 cell count. E2 was significantly positively associated with distensibility among HIV-infected women with CD4 count less than 350 cells/μL.

CONCLUSIONS

HIV-infected women had reduced estrogen and androgen compared with HIV-uninfected premenopausal women. T deficiency is linked with carotid artery stiffness, regardless of immune suppression, whereas E2 deficiency is linked with carotid stiffness among immunocompromised HIV-infected premenopausal women. Further research is warranted to understand the impact of endocrine dysregulation on the accelerated cardiovascular disease risk in HIV-infected women.

Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging

OBJECTIVE

The aim of this article is to summarize the recommended updates to the 2001 Stages of Reproductive Aging Workshop (STRAW) criteria. The 2011 STRAW + 10 reviewed advances in understanding of the critical changes in hypothalamic-pituitary-ovarian function that occur before and after the final menstrual period.

METHODS

Scientists from five countries and multiple disciplines evaluated data from cohort studies of midlife women and in the context of chronic illness and endocrine disorders on change in menstrual, endocrine, and ovarian markers of reproductive aging including antimüllerian hormone, inhibin-B, follicle-stimulating hormone, and antral follicle count. Modifications were adopted by consensus.

RESULTS

STRAW + 10 simplified bleeding criteria for the early and late menopausal transition, recommended modifications to criteria for the late reproductive stage (Stage -3) and the early postmenopause stage (Stage +1), provided information on the duration of the late transition (Stage -1) and early postmenopause (Stage +1), and recommended application regardless of women's age, ethnicity, body size, or lifestyle characteristics.

CONCLUSIONS

STRAW + 10 provides a more comprehensive basis for assessing reproductive aging in research and clinical contexts. Application of the STRAW + 10 staging system should improve comparability of studies of midlife women and facilitate clinical decision making. Nonetheless, important knowledge gaps persist, and seven research priorities are identified.

Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging

OBJECTIVE

The aim of this article is to summarize the recommended updates to the 2001 Stages of Reproductive Aging Workshop (STRAW) criteria. The 2011 STRAW + 10 reviewed advances in understanding of the critical changes in hypothalamic-pituitary-ovarian function that occur before and after the final menstrual period.

METHODS

Scientists from five countries and multiple disciplines evaluated data from cohort studies of midlife women and in the context of chronic illness and endocrine disorders on change in menstrual, endocrine, and ovarian markers of reproductive aging including antimüllerian hormone, inhibin-B, follicle-stimulating hormone, and antral follicle count. Modifications were adopted by consensus.

RESULTS

STRAW + 10 simplified bleeding criteria for the early and late menopausal transition, recommended modifications to criteria for the late reproductive stage (Stage -3) and the early postmenopause stage (Stage +1), provided information on the duration of the late transition (Stage -1) and early postmenopause (Stage +1), and recommended application regardless of women's age, ethnicity, body size, or lifestyle characteristics.

CONCLUSIONS

STRAW + 10 provides a more comprehensive basis for assessing reproductive aging in research and clinical contexts. Application of the STRAW + 10 staging system should improve comparability of studies of midlife women and facilitate clinical decision making. Nonetheless, important knowledge gaps persist, and seven research priorities are identified.

Menstruation and the menopausal transition

This paper characterizes changes in menstrual bleeding during perimenopause,including bleeding changes that represent markers of the menopausal transition. Recent results from the Study of Women's Health Across the Nation and other cohort studies are reviewed. Emerging data describing subpopulation differences in the transition experience are highlighted. When treating women in the midlife, clinicians should pay careful attention to medical factors, including both conditions and treatments, that may increase menstrual blood loss or alter menstrual cycle characteristics sufficiently to obscure the onset of the menopausal transition or the final menstrual period.

Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging

OBJECTIVE

The aim of this article is to summarize the recommended updates to the 2001 Stages of Reproductive Aging Workshop (STRAW) criteria. The 2011 STRAW + 10 reviewed advances in understanding of the critical changes in hypothalamic-pituitary-ovarian function that occur before and after the final menstrual period.

METHOD(S)

Scientists from five countries and multiple disciplines evaluated data from cohort studies of midlife women and in the context of chronic illness and endocrine disorders on change in menstrual, endocrine, and ovarian markers of reproductive aging including antimüllerian hormone, inhibin-B, follicle-stimulating hormone, and antral follicle count. Modifications were adopted by consensus.

RESULT(S)

STRAW + 10 simplified bleeding criteria for the early and late menopausal transition, recommended modifications to criteria for the late reproductive stage (Stage -3) and the early postmenopause stage (Stage +1), provided information on the duration of the late transition (Stage -1) and early postmenopause (Stage +1), and recommended application regardless of women's age, ethnicity, body size, or lifestyle characteristics.

CONCLUSION(S)

STRAW + 10 provides a more comprehensive basis for assessing reproductive aging in research and clinical contexts. Application of the STRAW + 10 staging system should improve comparability of studies of midlife women and facilitate clinical decision making. Nonetheless, important knowledge gaps persist, and seven research priorities are identified.

Executive summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging

OBJECTIVE

The aim of this article is to summarize the recommended updates to the 2001 Stages of Reproductive Aging Workshop (STRAW) criteria. The 2011 STRAW +10 reviewed advances in understanding of the critical changes in hypothalamic-pituitary-ovarian function that occur before and after the final menstrual period.

METHODS

Scientists from five countries and multiple disciplines evaluated data from cohort studies of midlife women and in the context of chronic illness and endocrine disorders on change in menstrual, endocrine, and ovarian markers of reproductive aging including antimüllerian hormone, inhibin-B, follicle-stimulating hormone, and antral follicle count. Modifications were adopted by consensus.

RESULTS

STRAW +10 simplified bleeding criteria for the early and late menopausal transition, recommended modifications to criteria for the late reproductive stage (Stage -3) and the early postmenopause stage (Stage +1), provided information on the duration of the late transition (Stage -1) and early postmenopause (Stage +1), and recommended application regardless of women's age, ethnicity, body size, or lifestyle characteristics.

CONCLUSIONS

STRAW +10 provides a more comprehensive basis for assessing reproductive aging in research and clinical contexts. Application of the STRAW +10 staging system should improve comparability of studies of midlife women and facilitate clinical decision making. Nonetheless, important knowledge gaps persist, and seven research priorities are identified.

HIV and the menopause

Dramatic improvement in the survival of the HIV population has occurred with the ascendance of highly active antiretroviral therapy (HAART). In the foreseeable future, HIV-infected women who acquired disease during the peak years of the epidemic are expected to survive to experience menopause and even years beyond. The HIV epidemic may be viewed as 'mature', as its earlier victims become part of the geriatric population. Research about the process of menopause in HIV-infected women and, conversely, about HIV infection in women undergoing menopause is currently limited. Existing research suggests that the process of menopause is affected by HIV infection, inasmuch as infected women appear to experience menopause at an earlier age, with greater symptomatology, and with different reproductive hormone profiles compared with HIV-uninfected women. HIV infection also appears to affect bone mineral density, cardiovascular disease and cognition, with some age-related interactions. Lifestyle and demographic factors have pervasive importance for both HIV infection and the menopause in women. This article reviews the current state of knowledge about the menopausal process in HIV-infected women, and the common conditions in postmenopausal women that are likely to be affected by HIV infection. Clinicians should appreciate the potential role of HIV infection in caring for menopause-aged women.

Health concerns of mature women living with HIV in the midwestern United States

This study was performed to better understand the health concerns of mature Midwestern women living with HIV and to offer health care providers information about the spectrum of medical and psychosocial needs of this population. Individual interviews were conducted with 18 low-income women who were 41 to 68 years of age. Interviews showed multiple needs that encompassed both physical and emotional health: more frequent health screenings, the ability to differentiate symptoms of advancing HIV from those of aging, desire for knowledge about reasonable expectations for aging women with HIV, and attention to emotional health needs and social support. Interventions aimed at helping mature HIV-infected women cope as they age, education about the normal aging process, consumer information about appropriate timing of health care screenings, and mechanisms to facilitate the creation of social support networks to decrease isolation seem to be needed in this population.

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.

Age at menopause of HIV-infected women: a review

The advent of highly active antiretroviral therapy has promoted a reduction in mortality due to HIV. Thus more women are living longer after receiving a diagnosis of HIV infection. With an increase in survival, topics related to the menopausal transition in HIV-infected women have emerged, such as age at menopause, bone mineral density and menopause-related symptoms. To this end, several studies have investigated age at menopause (AM) in HIV-infected women. The present paper reviews these studies and discusses the possible clinical implications of determining AM for HIV-positive women.

Factors affecting reproductive hormones in HIV-infected, substance-using middle-aged women

OBJECTIVE

To determine whether reproductive hormone levels are affected by human immunodeficiency virus (HIV) and drug use.

DESIGN

HIV-infected and uninfected women (N=429), median age 45, were interviewed on menstrual frequency, demographic and psychosocial characteristics, and drug use behaviors. Serum was obtained on cycle days 1 to 5 in women reporting regular menses. Premenopausal-, early menopausal, and late menopausal transition and postmenopausal stages were assigned based on menstrual history. Serum was assayed for follicle-stimulating hormone (FSH), estradiol (E2), luteinizing hormone (LH), prolactin, thyroid-stimulating hormone, and inhibin B. Body mass index, HIV serostatus, and CD4+ counts were measured. Factors associated with hormone concentrations were assessed using uni- and multivariable analyses. Hormone concentrations were compared within menstrual status categories using nonparametric comparisons of means.

RESULTS

In this cross-sectional analysis, LH and FSH increased, and E2 and inhibin B were significantly lower in women of older age and more advanced menopausal status. Increased body mass index was strongly associated with decreased LH. Opiate use was significantly associated with lower inhibin B and E2 and increased prolactin. Poorer self-rated health was statistically significantly associated with lower LH and FSH, but increased education was associated with higher LH and FSH. Among HIV-seropositive women, opiate users had detectably lower FSH and LH than nonusers, and use of highly active antiretroviral therapy was significantly related to higher LH, FSH, and E2, whereas cocaine use was associated with lower E2.

CONCLUSIONS

Age and menopausal status are strongly related to reproductive hormones. Body mass index and use of opiates, cocaine, and highly active antiretroviral therapy as well as educational attainment and perceived health can significantly modify reproductive hormones during the menopausal transition and need to be considered when interpreting hormone levels in middle-aged 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.