Advertisement
The Body: The Complete HIV/AIDS Resource
Follow Us Follow Us on Facebook Follow Us on Twitter Download Our App
Professionals >> Visit The Body PROThe Body en Espanol
Read Now: TheBodyPRO.com Covers AIDS 2014
  
  • Email Email
  • Printable Single-Page Print-Friendly
  • Glossary Glossary

Gynecological Complications in Women with HIV

December 1998

A note from TheBody.com: Since this article was written, the HIV pandemic has changed, as has our understanding of HIV/AIDS and its treatment. As a result, parts of this article may be outdated. Please keep this in mind, and be sure to visit other parts of our site for more recent information!

While gynecological (GYN) complications are but one area of concern for women with HIV, they are critically important because they are the most commonly reported condition of women living with HIV and AIDS. When evaluating HIV-associated GYN conditions and the provision of appropriate gynecological care, it is important to consider what GYN health reveals about the status of a woman's immune system.

What does it say about the health of a woman's immune system, for instance, when a common GYN condition like vaginal candidiasis becomes progressively more difficult to treat? What does the absence of an HIV infected woman's period (amenorrhea), a common menstrual abnormality in women with HIV, tell us about immune function? How does the marked increase in the rate and severity of cervical abnormalities experienced by women with HIV correspond to a weakening immune system? These are some of the questions that must help guide women and health care providers in the evaluation and treatment of GYN complications in women with HIV. These complications should also be considered in light of CD4+ cell count, an important marker of immune function. A chart of common GYN conditions and a flow chart of screening guidelines are presented below.


Common GYN Complications

Vaginal candidiasis (vaginal yeast infections) is a fungal infection common in many women. It is the most common initial manifestation of HIV in women, and its prevalence increases as CD4+ cell counts decline. As immune suppression worsens, the primary location of the candida infection may shift from the vagina to the mouth (for more information on candidiasis, call our hotline and request the Candidiasis Fact Sheet). Recurring vaginal candidiasis is often associated with more rapid HIV disease progression.

Advertisement
Fortunately, there are several effective forms of treatment for vaginal candidiasis, including topical creams and suppositories such as clotrimazole (GyneLotrimin®) which are available over-the-counter and by prescription. If the candidiasis is unresponsive to such treatment, the antifungal drug fluconazole (Diflucan® ) may be necessary. For women not responding to fluconazole, the antifungal ketoconazole (Nizoral®) may be an effective alternative. Dietary modifications such as decreasing sugar intake or adding lactobacillus containing yogurt or acidophilus capsules may help prevent recurrences of candidiasis. Refraining from using bleach and fabric softeners when doing laundry might also be useful.

Several studies show that the sexually transmitted disease, herpes simplex virus (HSV) type II, may take an altered course in HIV-infected people. For instance, the painful sores in and around the genitals and/or anus caused by herpes tend to be more frequent, persistent and requiring of higher doses of treatment in people with HIV. HSV ulcers persisting for over 1 month are associated with severe immunosuppression and are considered an AIDS-defining illness. Acyclovir (Zovirax®), an oral pill, is most commonly used to treat genital herpes. For women with frequent HSV outbreaks, acyclovir may be helpful in preventing future outbreaks.

Pelvic inflammatory disease (PID) represents a range of inflammatory disorders of the upper genital tract, including fallopian tubes, uterus, ovaries and, in advanced stages, abdominal lining. Common symptoms of such inflammation involve chronic, moderate-to-severe pain, tenderness in the abdomen, irregular menstrual cycles, non-menstrual bleeding and painful and frequent urination. Like other gynecological conditions, PID appears to be more prevalent, severe and resistant to treatment among women with HIV, and especially women with AIDS. Indeed, the Centers for Disease Control and Prevention recommends hospitalization and intravenous antibiotics for treating PID in women with HIV. Studies indicate that relapse of PID occurs more often in women with impaired immunity.

Human papillomavirus (HPV), a sexually transmitted disease which primarily affects the cervix, plays a primary role in the development of cervical dysplasia (abnormal cells) and cancer of the cervix in women. Recent studies have demonstrated that women with HIV, particularly those with low CD4+ cell counts, have an increased frequency and severity of HPV-related cervical dysplasia. The outcome for HIV-positive women with cervical cancer, the most severe form of cervical dysplasia and an AIDS-defining illness, is much worse than for women without HIV. However, if detected early, less severe grades of dysplasia (CIN I or II) are fairly easily treated, stressing the need for regular and timely screening.

If symptoms occur, they often include multiple small warts on the vagina or around the anus. Multiple types of therapy are available. However, recent studies caution against the use of one common treatment option called cryotherapy, which involves freezing the wart. Cryotherapy can cause normal tissue to heal over deeper areas of dysplasia, causing future genital screenings to appear normal while abnormal tissue grows undetected underneath. Anecdotal reports also indicate that the aftermath of cryotherapy can be extremely painful.


Screening

Given that women with HIV have higher rates and generally more severe cases of GYN complications, it is important to screen frequently and regularly. Screening is normally done with one of two diagnostic tools, the Pap smear and/or colposcopy.

The ability of Pap smears to adequately screen for cervical cancer in women with HIV is currently under debate. Studies have shown that 15-30% of Pap smears that are considered normal are, upon subsequent colposcopy and biopsy, found to be "false-negative." In other words, abnormal pre-cancerous cell growth passed undetected during the Pap test. The problem of false-negative Pap smears has lead some health care providers to suggest colposcopy plus biopsy as a more accurate screening procedure, particularly among HIV-positive women where early detection is most critical.

Still, colposcopy has drawbacks of its own. Not only does it require management by a specialist, colposcopy is often accompanied by a biopsy and can be a painful experience with some risk of infection and bleeding. At this point, it is difficult to say whether or not colposcopy screening is a necessary routine screening procedure for HIV-positive women without signs of an abnormal Pap smear. A promising new screening tool called Pap Plus Speculoscopy (PPS) has recently gained FDA approval. It is almost as sensitive as a colposcopy plus biopsy, is less invasive and painful and does not require a specialist.


Conclusion

Many of the GYN complications HIV-positive women experience also affect women who are not living with HIV. The same conditions tend to occur more frequently, are more serious and more difficult to treat in women with a compromised immune system. At the same time, GYN complications further compromise the immune system. Consequently, it is very important that GYN complications be diagnosed, monitored and treated under the guidance of a health care provider.

For more complete information, call Project Inform's National HIV/AIDS Treatment Hotline and request the Gynecological Conditions in Women with HIV Fact Sheet.


Common GYN Complications in Women with HIV/AIDS

This table is a partial listing of complications. For complete information, Call Project Inform's National Treatment Hotline at 800-822-7422 and request the GYN Conditions in Women with HIV Fact Sheet.


Complication Symptoms Diagnosis Treatments
Vaginal Candidiasis
(Vaginitis, Yeast Infection)

Fungal infection of the vulva and vagina. It is the most common initial manifestation of HIV infection in women and one of the most common complications experienced.

Vulvar itching with a thick vaginal discharge; burning upon urination; redness and white patches at the sites of infection; occurrence of pain during penetrative sexual intercourse. Usually first diagnosed by appearance and symptoms. If symptoms do not resolve after initial treatment, lab tests may be performed. Topical creams and suppositories such as clotrimazole (GyneLotrimin®) are available by prescription or over-the-counter. The antifungal fluconazole (Diflucan®) orally, 200mg 3 times a day/every 4 days); ketoconazole (Nizoral®), 400mg a day for 14 days.
Chlamydia

A bacterial infection which often affects the cervix and pelvic organs. Most commonly sexually transmitted.

Unusual vaginal discharge and burning when urinating. Later symptoms include lower abdominal pain; pain during penetrative intercourse; bleeding between periods and low-grade fever. Laboratory inspection of fluid from an infected site. Antibiotics such as azithromycin (Zithromax®), ceftriaxone (Rocephin®), or doxycycline taken orally.

Note: treat sexual partners even if they have no symptoms. Avoid sex until treatment is completed.

Gonorrhea

A bacterial infection that is sexually transmitted.

Pus-like discharge from cervix; lower abdominal pain; fever. Culturing fluid from the cervix, vagina or urethra. Penicillin, tetracycline and/or cephalosporin taken orally.
Pelvic Inflammatory Disease

Serious, potentially life-threatening spectrum of inflammatory disorders in genital tract of women. Often caused by untreated sexually transmitted infections, particularly chlamydia and gonorrhea.

Chronic, moderate-to-severe pain in the abdomen; irregular menstrual cycles; non-menstrual bleeding; increased vaginal discharge; painful and frequent urination; nausea and fever. Usually diagnosed by symptoms and pain on the pelvic exam. Sonogram may be performed and occasionally a surgical diagnosis is required. Combination of antibiotics including clindamycin (Cleocin®), gentamicin, cefoxitin (Metoxin®) or a combination of cefoxitin and doxycycline.
Human Papillomavirus

Viral infection of multiple types that lead to the disruption of the genital cell structures, particularly the cervix. Some HPV types are associated with high risk of cervical cancer or precursor lesions (CIN, SIL).

Symptoms frequently not experienced. Sometimes there are multiple small warts (white spots) on the vagina or around the anus; vaginal discharge or, rarely, pain during penetrative sexual intercourse. Can often be diagnosed visually, but diagnosis should be made by biopsy since warts may be associated with cancer or pre-cancer lesions any-where in the genital tract. Diagnosis can be made by Pap smear, but should follow up with colposcopy. Multiple options to remove viral symptoms include:
  • trichloro-acetic acid (strong acid solution);
  • electro-cautery (tissue destruction by electric current); and
  • imiquimod (Aldara®)
Cervical Intraepithelial Neoplasia (CIN)

Dysplasia of the surface layers of the cervical cells. CIN is classified according to degrees of severity (grades I, II or III).

Symptoms frequently not experienced. Diagnosis is often made by Pap. Colposcopy plus biopsy is advised if Pap shows any atypical cellular activity (including persistent inflammation). CIN-I: no therapy needed.
CIN-II-III:
  • laser vaporization;
  • loop electric excision procedure (LEEP);
  • biopsy; and
  • cryotherapy (This option may be least desirable; it may mask future problems).
Herpes Simplex Virus

Infection caused by herpes virus types II or I. Type II herpes (genital herpes) is transmitted sexually.

Herpes Simplex I commonly produces oral herpes, and is characterized by cold sores or fever blisters on the mouth or eyes. Herpes Simplex II causes painful sores in the genitals and anus; itching and soreness may present before outbreak; painful urination; swollen lymph nodes in groin; muscle aches; fever. Can sometimes be diagnosed by visual exam. Some fluid from the sores should be taken to culture (try to grow in a laboratory) to confirm infection. Blood tests can also confirm infection, but not if infection is currently active. Type I and II:
  • Acyclovir (Zovirax®) in topical, oral and, in severe cases, intravenous form. Oral acyclovir, 200mg five times a day for 10 days, is the general recommendation.
  • For frequent and severe cases, oral acyclovir may be used at 200 to 400mg two to five times a day.
Bacterial Vaginosis

A bacterial infection of the vagina. Can be sexually transmitted.

Odorous, frothy discharge; Inflammation of the vagina. Microscopic inspection of vaginal discharge. Metronidazole (MetroGel®) taken orally

Note: treat female sex partners.

Trichomonas (Trich)

A protozoal infection of the urethra and vagina. Most commonly sexually transmitted.

Excessive and odorous yellow or green vaginal discharge; extreme itching and pain and soreness around the vagina. Microscopic inspection of vaginal discharge. Metronidazole (MetroGel®) taken orally.

Note: treat all sex partners.

Syphilis

A bacterial infection that is usually sexually transmitted.

May remain with no symptoms for years with initial presentation as a chancre (ulcer). If untreated, syphilis progresses through three stages: primary (painless ulcers or lesions); secondary (widespread lesions and swollen lymph glands); tertiary (advanced lesions in organs and tissues). Primary syphilis is usually diagnosed by microscopic evaluation of an ulcer scraping; secondary syphilis by the appearance of symptoms and blood tests; tertiary syphilis by positive blood tests. Penicillin or ceftriaxone taken orally.
Menstrual Disorders

Often accompany chronic illness. Specific disorders experienced by women with HIV may be exacerbated by weight loss, anemia, HIV medica-tions, street drugs and depression.

Absence or suppression of menstruation (amenorrhea); irregular periods; abnormally heavy or light periods; intermenstrual bleeding; worsening of symptoms asso-ciated with PMS. It is important to investigate menstrual disorders with a health care provider as such problems can adversely affect the health of a woman with HIV. Current standards of care for HIV-positive women neither approve nor forbid the use of hormonal therapies or birth control for menstrual regulation. Stress management and nutrition may relieve symptoms.
Cervicitis

Inflammation of the cervix, usually due to sexually transmitted diseases such as chlamydia, gonorrhea or trichomonas.

May have no symptoms. When present, symptoms may include intermenstrual bleeding; vaginal discharge that increases after menstruation; bleeding after penetrative intercourse; painful urination; low back pain. Diagnosis can be made upon visual examination of the cervix. Depending on the cause of cervicitis, treatment options include: tetracycline, metronidazole or Ceftriaxone taken orally.
Molluscum

Viral infection that is transmitted via skin-to-skin contact.

Small dome-shaped, flesh-colored bumps (papules) on face or in the groin or genital skin. May cause itching and rapid spreading. Usually diagnosed by visual exam. Early biopsy is recommended for atypical lesions. Multiple removal options include:
  • topical application of liquid nitrogen;
  • electro-cautery (tissue destruction by electric current); and
  • surgical removal


GYN Screening Guidelines

As follow-up after any treatment for dysplasia, have a Pap smear at three months.

  • If result is negative, repeat a pap smear every three months for one year.

  • If result shows inflammatory changes, treat dysplasia again and repeat a pap smear at three months.

  • If result is abnormal, one of three conditions exist: atypical cells of undetermined significance (ASCUS); mild dysplasia; or moderate/severe dysplasia. Refer below for these conditions.
Atypical Cells of Undetermined Significance (ASCUS) Mild Dysplasia Moderate to Severe Dysplasia
If abnormal pap smear result shows ASCUS, a colposcopy is recommended.
  • If the colposcopy result is negative, repeat another colposcopy in 3 to 6 months.
  • If the colposcopy result is positive for mild ascus, repeat another colposcopy in 3 to 6 months.
  • If the colposcopy result is positive for moderate to severe ascus, your physician should diagnose and treat the condition
If abnormal pap smear result shows mild dysplasia, a colposcopy is recommended.
  • If the colposcopy result is negative, repeat another colposcopy in 3 to 6 months.
  • If the colposcopy result is positive for mild dysplasia, repeat another colposcopy in 3 to 6 months.
  • If the colposcopy result is positive for moderate to severe dysplasia, your physician should diagnose and treat the condition.
If abnormal pap smear result shows moderate to severe dysplasia, then a colposcopy is recommended.
  • Your physician should diagnose and treat the condition.


If no history of abnormal Pap or treatment in 12 months, have a Pap smear at three months.

  • If result is negative, repeat a pap smear every six months for one year.

  • If result shows inflammatory changes, treat dysplasia and repeat a pap smear at three months.

  • If result is abnormal, one of three conditions exist: atypical cells of undetermined significance (ASCUS); mild dysplasia; or moderate/severe dysplasia. Refer below for these conditions.
Atypical Cells of Undetermined Significance (ASCUS) Mild Dysplasia Moderate to Severe Dysplasia
If abnormal pap smear result shows ASCUS, a colposcopy is recommended.
  • If the colposcopy result is negative, repeat another  colposcopy in 6 months.
  • If the colposcopy result is positive for mild ascus, repeat another colposcopy in 6 months.
  • If the colposcopy result is positive for moderate to severe ascus, your physician should diagnose and treat the condition.
If abnormal pap smear result shows mild dysplasia, a colposcopy is recommended.
  • If the colposcopy result is negative, repeat another colposcopy in 6 months.
  • If the colposcopy result is positive for mild dysplasia, repeat another colposcopy in 6 months.
  • If the colposcopy result is positive for moderate to severe dysplasia, your physician should diagnose and treat the condition.
If abnormal pap smear result shows moderate to severe dysplasia, then a colposcopy is recommended.
  • Your physician should diagnose and treat the condition.


If there's a history of abnormal Pap or colposcopy in past 12 months, have a Pap smear at three months.

  • If result is negative, repeat a pap smear every six months for one year.

  • If result shows inflammatory changes, treat dysplasia again and repeat a pap smear at three months.

  • If result is abnormal, one of three conditions exist: atypical cells of undetermined significance (ASCUS); mild dysplasia; or moderate/severe dysplasia. Refer below for these conditions.
Atypical Cells of Undetermined Significance (ASCUS) Mild Dysplasia Moderate to Severe Dysplasia
If abnormal pap smear result shows ASCUS, a colposcopy is recommended.
  • Repeat colposcopy in 6 months.
If abnormal pap smear result shows mild dysplasia, a colposcopy is recommended.
  • Repeat colposcopy in 6 months.
If abnormal pap smear result shows moderate to severe dysplasia, then a colposcopy is recommended.
  • Your physician should diagnose and treat the condition.


Back to the Project Inform Perspective December 1998 contents page.

A note from TheBody.com: Since this article was written, the HIV pandemic has changed, as has our understanding of HIV/AIDS and its treatment. As a result, parts of this article may be outdated. Please keep this in mind, and be sure to visit other parts of our site for more recent information!



  
  • Email Email
  • Printable Single-Page Print-Friendly
  • Glossary Glossary

This article was provided by Project Inform. It is a part of the publication Project Inform Perspective. Visit Project Inform's website to find out more about their activities, publications and services.
 
See Also
More on HPV and Cervical Cancer in HIV-Positive Women

Tools
 

Advertisement