Menstrual Symptoms in HIV Positive Women

Many women with HIV infection complain of an abnormal or changing menstrual cycle, and clinicians experienced in the care of women with HIV infection often feel that a higher than expected percentage of women in their care complain of menstrual problems. The absence of a menstrual period (amenorrhea) or lighter than normal menstrual bleeding (oligomenorrhea) from an HIV-related cause is speculative. In men however, gonadal (testicular) failure has been reported from early on in the epidemic, as have low testosterone levels, impotence, and testicular atrophy. Gonadal (ovarian) failure in women could present as a menstrual cycle disturbance. Heavy bleeding (menorrhagia) or painful periods (dysmenorrhea) could be explained by low platelets (thrombocytopenia) associated with HIV infection, or a complication of severe pelvic inflammatory disease, both conditions frequently associated with HIV disease.

Optimal care of HIV-infected women includes a good understanding of the clinical manifestations of gynecologic disease. However, in HIV-infected women, little is known about menstruation and abnormal vaginal bleeding, despite the importance of the menstrual history in evaluating ovarian function and detecting gynecologic disorders. Virtually nothing is known about any potential effects of newer antiretroviral therapies on hormonal levels and menstrual cycles of women.

Evaluation of HIV-related effects on the menstrual cycle is complicated by the fact that substance abuse, chronic disease, and significant weight loss can result in dysregulation of the hypothalamus (a part of the brain that regulates sex hormone secretion) and affect menstruation. Early on in the epidemic, a few cross-sectional studies described a high prevalence of oligomenorrhea and amenorrhea in women infected with HIV. However, where the data were compared with a control group, the disparity between substance abuse in the two groups was significant or not addressed at all. Because of a lack of comparable control groups, these studies did not really answer the question of whether HIV infection has an independent effect of increasing menstrual abnormalities.

In a later study, 55 HIV positive women and a matched control group underwent detailed gynecologic assessment, 71% of the infected women had asymptomatic HIV disease. In this study, there were no significant differences in the prevalence of menstrual abnormalities between the two groups. A larger study of the same design also suggested that neither HIV infection nor immunosuppression has a clinically relevant effect on menstruation or other vaginal bleeding. In this study, most HIV-infected women menstruated about every 25-35 days, suggesting monthly ovulation (egg production) and an intact hormonal system.

HIV-infected women with abnormal or dramatically changed menstrual bleeding should have the full investigation accorded HIV-negative women to determine the cause of the abnormality. Heavy bleeding can cause anemia, a problem already prominent among women with advanced HIV infection, and can be a symptom of an underlying problem such as a fibroid tumor, blood clotting problems, or infection. Amenorrhea can be a symptom of pregnancy, ovarian cyst, ovarian failure, or menopause. Missing two periods (if pregnancy is ruled out) requires investigation by pelvic exam and blood tests to determine if the problem lies within the reproductive tract or not. In the course of identifying the cause of menstrual irregularities, women should report to their providers any change in drug therapy, use of recreational drugs, changes in weight, and all related symptoms.

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