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Hot Flashes and Healthful Living: Health Concerns for Women Growing Older With HIV/AIDS
A Conversation With L. Jeannine Bookhardt-Murray, M.D.

By Olivia Ford

March 28, 2013

L. Jeannine Bookhardt-Murray, M.D.

L. Jeannine Bookhardt-Murray, M.D.

Nowadays, more and more women living with HIV are planning for a life stage they may once have thought they wouldn't live to see: menopause. Menopause is a normal part of a woman's life -- and its effects vary widely from woman to woman, regardless of HIV status. But are some of the variations of menopause more pronounced for women living with HIV? How can a woman tell if what she's experiencing is a common menopause symptom or a side effect of the virus or her meds? What can women expect to happen as they enter menopause, and what other health issues should they be aware of?

To get some answers, we sat down with L. Jeannine Bookhardt-Murray, M.D., chief medical director at Harlem United Community AIDS Center in New York City. Dr. Bookhardt-Murray has more than two decades of experience treating women living with HIV/AIDS. She breaks down the basics of menopause, as well as health concerns ranging from uterine fibroids to breast health to depression -- and suggests lifestyle changes that may alleviate some of the effects of aging for women living with HIV/AIDS.

Can you explain a bit about menopause, generally? What are some of the common signs that women begin to see, and at what age?

Women usually start going through menopause at around the age of 45 -- that's the average age. Physically, they may see their periods start to get lighter -- less flow; the number of days may decrease. If a woman usually had a five-day cycle prior to menopause, it may come down to three days, with a lighter flow. They may have a period this month, and next month none. Over time it will lessen and lessen. This time of transition is called perimenopause; these signs, as with others, are going to vary from woman to woman.

Some other signs that women may also see when they're going through menopause:

We used to use estrogen therapy for those physical symptoms; but that's infrequently used now because of the association with the development of uterine cancer and breast cancer.

The way I was taught to think about menopause is that, if a woman has gone through a whole year without a period, they've hit menopause. I'm talking about regular, natural menopause, not premature menopause that sometimes happens to 30-year-olds.

"There's no definitive textbook case of menopause, because it varies from one person to another. The best thing a woman can do is talk to her mom, and find out what menopause was like for her mother. Usually the women in a given family -- mothers, sisters -- will follow the same kind of pathway through menopause."

The process of having periods may be over, but the other symptoms -- the mood changes, the hot flashes -- may continue for a number of years, and they may continue for the rest of the woman's life. And it varies. There's no definitive textbook case of menopause, because it varies from one person to another.

The best thing a woman can do is talk to her mom, and find out what menopause was like for her mother. Usually the women in a given family -- mothers, sisters -- will follow the same kind of pathway through menopause. Of course, oftentimes someone's mother is not around, or has passed away, or the woman may have been adopted or something like that. But that's a good way to look at it: Find out what the women in their family went through with menopause.

Can you give a quick overview of what's going on internally in a woman's body that produces the signs and symptoms of menopause? Basically, what is menopause from the inside?

From the inside, the hormones are changing. Estrogen levels are decreasing. That's the main issue with menopause: You're not maintaining the same level of estrogen that you did as a younger woman. The amount of estrogen produced by the ovaries and the little bit of estrogen produced from the uterus: The amount is declining, and it leads to this hormonal imbalance.

Is it common for women to see their periods stop but to still experience the symptoms of their cycles every month?

It is. Even though they're not ovulating successfully, there may be hormonal changes, and it may result in some cramping, bloating, and the usual premenstrual symptoms that women feel. That can even go on after a woman completes menopause. She may be one to two years out after having her last period; and still, every month, she's getting these symptoms like she's going to have her period. In a couple of years or so it usually tapers off. But it's very annoying. It's this whole process of having to wonder, Is my period really coming or isn't it? And If it isn't, what should I do?

The other thing is that, if women do develop any kind of bleeding, even period-like bleeding, after their periods have stopped, they need to see their doctor and talk to them about it. Because that could be a sign that something's wrong, including cancers.

What are some of the other potential reasons for abnormal bleeding after menopause, besides cancers? Is there ever bleeding associated with fibroids, ovarian cysts or anything like that?

No, not really. But it could be a problem with the lining of the uterus. It could be infection. It could be cancer. But we're not talking about a hormonal cause for bleeding, at this point. It's likely a structural issue -- a growth of some kind. There could be a tumor that breaks down and there's bleeding. But it's not a normal period.

How can a person tell the difference between the night sweats that people living with HIV often experience and the hot flashes that are associated with menopause?

Usually when women are going through menopause, there's a complex of symptoms: the hot flashes, and then the feeling cold, and the sweats. But you put it together, based on their report and their history, and it's not just night sweats alone, frequently; with menopause, they have other symptoms along with night sweats. So it's really what we call a clinical diagnosis, based on their history. We can also check a woman's estrogen level -- which may or may not be helpful. Just because a woman has a certain level of estrogen doesn't mean it's responsible for her symptoms. So the diagnosis of menopause is usually based on symptomatology, rather than any kind of lab report. We look for it when women hit about 45 years of age; we know that's the average age.


Are Hot Flashes More Frequent and Intense for Perimenopausal Women Living With HIV? (From TheBodyPRO.com)

Do HIV-positive women bear a heavier burden of one of the most bothersome symptoms of menopause than do HIV-negative women? A study at a recent huge HIV research conference delivers a tentative yes. There's still more to learn; Boston nurse practitioner Sara Looby, one of the study authors, explains her preliminary findings in this summary. She also shares recommendations for altering these symptoms with lifestyle changes like quitting smoking.

What have you seen as far as menopause and HIV that's different from what you might expect from a woman who's not living with HIV?

I've found that women who have very low CD4 counts, and have been maintaining low CD4 counts for a while, tend to go through menopause sooner than other women. I can't give you an exact age -- again, it's variable -- but I may find women with low CD4 counts going through menopause around the age of 40. That's the one area: Low CD4 counts seem to impact regular hormonal balance.

Other providers have reported that when the viral load is really, really high that that, too, can affect menopause. But I've not seen that firsthand. I've just seen low CD4 counts affecting menopause.

Does taking HIV meds factor into menopause at all? Can HIV meds intensify symptoms of menopause? Are any meds associated with hormonal balance issues?

No, not in any ways that I'm aware or have seen or read. But the one drug that I know can interfere with hormonal balance, that may be part of the lives of some women living with HIV, is methadone. Women who are on methadone tend to not have regular periods. So do women who are underweight. You may have a woman who has a diagnosis of AIDS and she's well underweight, and she may experience lack of periods.

What are some of the medical concerns that perimenopausal and postmenopausal women need to be aware of? Do those differ in women living with HIV? I've heard recently about bone mineral density and cardiovascular complications in menopausal women -- which, of course, are already of concern for people living with HIV.

Those are the major ones. Osteoporosis is a huge concern. There are a lot of data coming out showing that osteoporosis may be actually happening earlier in people living with HIV (men and women), anyway. So once a woman completes menopause the rates of osteoporosis may actually be going up.

There are a number of things that we need to do as far as women living with HIV and approaching menopause, like watch a woman's vitamin D level; make sure that vitamin D is replaced if the level is low; make sure that the woman is getting enough calcium, exercise and sunlight. Those are all very, very important.

Smoking impacts bone density; we know that a large number of people with HIV infection are heavy smokers. We want to try to get them off of the tobacco, because that does weaken the bones.

I imagine that smoking cessation and exercise would have an effect on cardiovascular concerns, as well. Are there any other lifestyle changes that you recommend to older women specifically who are dealing with menopause, as far as mediating some of the cardiovascular issues? Or are medications the only answer?

"There are some situations where medications are absolutely important -- like with HIV -- but for many of the diseases that we get in life, we can prevent them, or at least make a big impact on them, by lifestyle changes."

No. I'm not a lover of medications. There are some situations where medications are absolutely important -- like with HIV -- but for many of the diseases that we get in life, we can prevent them, or at least make a big impact on them, by lifestyle changes.

When I say lifestyle changes, I mean a comprehensive package. Here's what I talk to my patients about:

The thing I worry about is that women don't often take care of themselves. Women have traditionally taken care of everyone else. And when it comes time to taking care of ourselves, sometimes we don't even know how to do it. We need to learn how to take care of ourselves, and keep ourselves healthy.


Alternative Treatments and Keeping Healthy After Menopause
In "Menopause and HIV" (From the Well Project)

There are other therapies available to treat menopausal symptoms, and a number of ways to stay on top of your health following menopause. Check out this list of tips and suggestions from the Well Project -- and for women who choose alternative therapies, it's best to consult a skilled practitioner and let your regular health care provider know exactly what you are doing.

How do you start those conversations about self-care, specifically with older women living with HIV?

I just start out by talking to them, asking them, "How's your diet? What do you eat?" and really finding out what their goals are -- how healthy they feel now; how healthy they want to feel; and then some time frames for changes they're going to make in their lives.

I really want them to work toward goals. If it's quitting smoking, and they're ready to set a quit date, we set a quit date. If they're ready to give up carbonated beverages, we set a quit date. It's really about having goals that they work toward over time, taking baby steps. Some people can leap and make a lot of changes at once. But I don't find most people can do that.

Do you find that your older women clients who are living with HIV are particularly reticent to speak about issues surrounding their periods and menopause? Do you find that you are often initiating that conversation, or does it usually flow pretty freely? Do you have any advice for any other providers working with older women, as far as starting those conversations?

Again, I think it gets back to the issue of women not taking care of themselves or advocating for themselves. They don't often bring the issue up, so I usually initiate the conversation. I know when the last period was for all of my women patients, even if it was 10 years ago.

We talk about the issues around getting older. What I find is that women will come in with questions about things that are happening to their body, and then want to know if it's because of HIV. Not having periods isn't one of them -- and I think because women hit a certain age and just expect their periods to stop. But they're not bringing up some of the symptoms that they're having as a result of periods stopping. They're just kind of trying to muddle through. They'll bring up the pain in their ankle, but they won't bring up symptoms of menopause, usually.

Are there any particular symptoms of menopause that women are more reticent to talk about?

Vaginal dryness is a big one. As women get older, their vaginas do get dry. If they do have a love life, it interferes with sexual activity. It makes them think something is wrong with them. It kind of feeds into that whole idea of, I'm getting old and I'm useless. Vaginal dryness is something that really has to be addressed.

We do our best to treat it with water-based lubricants. There are some plant-based hormonal vaginal inserts that can be used, and things like that. There are things that can be done.

It seems that vaginal dryness could also have some bearing on HIV prevention, because of the increased likelihood of the vaginal skin tearing during intercourse. Whether it's an HIV-negative woman who has a partner who's HIV positive, or vice versa, there's increased transmission risk for the HIV-negative partner, if there is one involved. It's great that that conversation happens around treating vaginal dryness.

And it's very important for women who are menopausal to continue using condoms. But they have to also make sure that there's plenty of lubrication there, so there are no tears, cuts or discomfort. Condoms can be a little harsh for some women. In addition to making sure their partner is using condoms, if it's a male-female relationship, they just want to make sure they're lubricated, as well.

I've heard that menopause often comes up, as far as older adults and HIV, as a reason why condoms aren't used. Is that correct?

Right.

"Patients really do want to talk about sex, but they're not going to initiate the conversation. ... You have to put it out there to let them know it's OK to talk about, or they will never bring it up."

Sometimes, an older woman might think, I'm going through menopause, so I'm not going to get pregnant; and of course, pregnancy is not the only concern with sex.

The other thing I just want to say in the case of people who may be using sex toys, the same thing is important: If there's vaginal drying, there needs to be plenty of lubrication that's being used so there is no injury to the tissue.

How do you start conversations with clients dealing with menopause about HIV and sexually transmitted diseases, and introduce condoms into the conversation?

My thing about being a middle-aged physician is that I can talk about whatever I want; and I don't get embarrassed. I just bring it up: "Are you sexually active?" I may introduce it by saying, "I want to talk to you about sex."

Patients really do want to talk about sex, but they're not going to initiate the conversation. So I'll open it up with, "I want to talk to you about sex. Do you have any questions for me?" And that opens up the conversation. But you have to put it out there to let them know it's OK to talk about, or they will never bring it up.


HIV and Sexual Function in Women Over 50
By Bethsheba Johnson, G.N.P.-B.C., A.A.H.I.V.S. (From TheBodyPRO.com)

"Where are the articles on women's sexual function -- and the sexual dysfunction drugs in the development pipeline -- as there are for men?" asked nurse practitioner Bethsheba Johnson in this blog entry from late 2011. She compiled a review of some of the recent literature looking into the sexual lives of women over 50 living with HIV. It's a resource that older women living with HIV may want to share with their own providers.

Switching gears a little bit, can you talk about the connection, if there is any, between uterine fibroids and menopause? Can they contribute in any way to the early onset of menopause, or have any effect on its progression, or vide versa?

Fibroids are very common. They can be small, or they can be large. They can cause abnormal bleeding. Sometimes they can cause a lot of pain. So it's important to know what's going on with that fibroid -- to have it looked at, to make sure there's no cancer hiding in there. Usually, doctors will want to do little biopsies, or something like that, to make sure that it's safe.

Fibroids are really problematic when a woman is trying to get pregnant. It can disrupt the uterine lining, the surface of the uterus; and then it's hard for the egg to implant.

As a woman gets older and her estrogen levels are dropping, the fibroids may actually get smaller over time. It's the estrogen that feeds the fibroid; with time, they may not need the surgery. The pain may go away; the abnormal bleeding may go away; and they might be able to get through.

I would say to women: If you have a large fibroid that's causing problems, just wait till you go through menopause, and it may get better. Every single time a woman has abnormal bleeding, like heavy bleeding or irregular periods, and they have a fibroid, they need the fibroid to be looked at. But I wouldn't rush under the knife if there are no signs of cancer.

Are there any differences in management or treatment of fibroids between women who are living with HIV and HIV-negative women?

Not really. I would say the one thing is, if surgery is in the picture, that the CD4 count really should be a healthy CD4 -- say, above 200 -- because the postoperative recovery period is much better when the CD4 count is higher, and you lessen the risk of postoperative infections.

Have you seen, in research or in practice, whether women of color are more or less likely to have fibroids?

I have not seen it in research; but in my practice, in which probably 99 percent of the women are of color -- fibroids are very common. Over half of my women have fibroids. I don't know how that compares to the world of people without HIV infection. But women of color may be more likely to have fibroids.

A recent study came out that found that women who are experiencing menopause and were living with HIV were more likely to experience symptoms of depression than their HIV-negative counterparts. The study was actually not able to discern why. Could you shed some light on the topic, and what you'd recommend to women who are experiencing an increase in depression?

Overall, people with HIV experience increased rates of depression, as compared to the general population. But a lot of people don't know -- a lot of women don't know -- that help is available.

There is a lot of stigma to having depression. So that's another question I throw out there to my patients: "Are you having any depression?" Some women don't know what depression means. So I'll put it in terms of, "Are you feeling down, depressed or hopeless?" "Have you lost interest in doing things?" Those kinds of general questions will usually get a woman to open up.

They need to be able to talk about it. Often the provider has to open the conversation because of the stigma around mental illness, especially among people of color.

Also, some women will not talk about being depressed because they think the only answer is going on antidepressant medication. But there are things to try, like talk therapy, or psychotherapy. I'm a strong believer in getting back to healthful living, and just following the basics. We know that sunshine and fresh air does a lot for the mood, so I really push the healthful style of living with my patients, especially when they're depressed. Get out of that dark room. People who are depressed tend to stay in bed with the covers over their head, and keep the drapes closed. But sometimes it can help to get up and get out.

Is there any other information you'd like to share with women who may be facing menopause, or just generally growing older, with HIV?

"While cervical cancer rates go down as a woman gets older, breast cancer rates go up, especially after menopause. So women should be paying attention to making sure that they're up to date with their mammograms."

I would like to talk about the relationship between aging and breast cancer. While cervical cancer rates go down as a woman gets older, breast cancer rates go up, especially after menopause. So women should be paying attention to making sure that they're up to date with their mammograms.

What's the current recommendation as far as how often a woman should get a mammogram, and at what age?

If a woman is 50 or older, she should have a mammogram every year. At the age of 40 she should at least have a breast cancer screening, and then talk to her doctor about the regularity with which she needs to do that mammogram.

Do you recommend that women do breast self-exams?

I would say just be aware of what's going on with your breasts. Check them in the shower. There used to be a recommendation that women check their breasts once a month in the shower. But women actually check their breasts more often. So I would recommend that women check their breasts on a regular basis, looking for any lumps or bumps or areas of discomfort.

If you could just share one general piece of advice with a wide swath of women living with HIV and anticipating menopause, what would that advice be?

For the smokers, I would say address the smoking issue and quit using tobacco. Smoking complicates everything, and it makes it difficult for women to develop effective coping strategies: Instead of coping, they'll smoke, when they may need psychotherapy, or some other intervention. I would say stop smoking; that's the main thing. Stop smoking and get back to basics with healthful living.

This transcript has been edited for clarity.




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