It's hard to get information about HIV and women's health issues. Yes, I'm talking about birth control, yeast infections and menopause. As a woman living with HIV, what do I need to know about my health down there?
-- E.R., Kamloops, BC
Mona Loutfy, M.D., Infectious Diseases Specialist, Women's College Hospital, Toronto
Certain gynecological conditions that are already quite common among women are even more common, severe and difficult to treat in women with HIV. These include vaginal infections, such as yeast infections and bacterial vaginosis; sexually transmitted infections (STIs), such as chlamydia, gonorrhea, herpes and syphilis; and pelvic inflammatory disease, a potentially serious bacterial infection of the reproductive system.
Recurrent yeast infections can be a warning sign for women who have not yet been diagnosed with HIV. For HIV-positive women, recurring infections can be a sign of a weakening immune system.
The treatments for these common infections are generally the same for women with and without HIV. It's important to know that having an STI increases your risk of transmitting both the STI and HIV. Bacterial vaginosis may also increase the risk of passing HIV. You can reduce the risk of many STIs by using condoms during sex.
Women with HIV have higher rates of problematic strains of a common STI known as the human papillomavirus (HPV). These problematic strains can cause genital warts, cervical cancer and cervical dysplasia, an abnormal change in the cervix that can progress to cancer when left undetected.
In the year following your HIV diagnosis, book a pelvic exam, including a Pap test, every six months. Your doctor will do an examination of your inner and outer pelvic area and take a tiny sample of cells from your cervix to check for cervical dysplasia or cancer and various other diseases and infections. If these tests uncover no significant problems, a yearly pelvic and Pap test will suffice.
The condom -- despite its relatively high failure rate at preventing pregnancy (12 percent) -- is the most common and important form of contraception for women with HIV because it is the only one that blocks the transmission of HIV and most other STIs. To prevent pregnancy, a second method of contraception should be used in addition to condoms. This is particularly important in situations where women don't have a great deal of control over when or how they have sex.
Some women choose oral hormonal contraception (the birth control pill). However, women on anti-HIV therapy should be aware that there can be drug interactions between some anti-HIV drugs and the hormones in many birth control pills. Talk to your doctor about your birth control options if you are taking:
- atazanavir (Reyataz; unboosted or boosted with ritonavir [Norvir])
- ritonavir-boosted darunavir (Prezista)
- fosamprenavir (Telzir; unboosted or boosted with ritonavir)
- Kaletra (lopinavir/ritonavir)
- nevirapine (Viramune)
- ritonavir-boosted saquinavir (Invirase)
- ritonavir-boosted tipranavir (Aptivus)
There are other forms of hormonal contraception, including injections and intrauterine devices, that contain other hormones. Talk with your doctor about whether they might be appropriate for you.
Tasleem Kassam, N.D., Clinic Director, Effective Health Solutions, Calgary
Women with HIV are often plagued by stubborn yeast infections that won't go away. Naturopathic doctors recommend fending off chronic yeast infections by changing your diet. Since yeast feeds on sugar, avoid simple sugars and refined carbohydrates as much as you can; instead choose vegetables and high-protein foods. No diet should be taken to the extreme -- a variety of fresh, unprocessed foods is best for optimal health.
Secondly, probiotic supplements are useful to restore your vagina's flora (healthy bacteria) balance. We are often unaware of our exposure to antibiotics as a regular part of our food supply; this can affect the beneficial bacteria so critical not only to gastrointestinal health but to vaginal health and immune function as well.
During an active yeast infection, I recommend alternating between a probiotic douche and a garlic pessary. To make the douching solution, mix 1⁄8 cup of lukewarm water with 1⁄4 to 1⁄2 teaspoon of probiotic powder. (The powder is available at health food stores or you can simply break open probiotic capsules.) Before showering, flush your vagina with the solution using a vaginal bulb syringe, which can be found in any pharmacy. A large syringe will also work. Make sure you use lukewarm water -- hot water will kill the live bacteria and cold water will feel unpleasant.
I advise my patients to use a garlic pessary on alternate nights. Peel a clove of garlic -- avoid nicking it and releasing any juice that might cause irritation -- and then wrap it in gauze. Form a tail with the gauze to make it easy to remove. Apply coconut or olive oil to lubricate the pessary and then insert it as high as possible into your vagina and leave it there overnight. Allicin, a natural compound in garlic, helps kill yeast. Garlic is an antibacterial agent, so you can also use it to fight off bacterial infections such as bacterial vaginosis.
Naturopathy advocates the importance of addressing the body's ecological balance as part of treating the infection instead of simply taking the standard prescription medications. It's kind of like trying to get rid of dandelions without pulling out the roots -- you may get rid of one infection but you won't stop them from recurring.
Debbie Kelly, Pharm.D., Pharmacist, Newfoundland and Labrador HIV Clinic, St. John's
In most cases, treatments for yeast infections are the same for all women regardless of whether or not they have HIV. I tend to recommend antifungal creams and ovules (such as Monistat) over the single fluconazole tablet as a first treatment because we don't want to create instances of fluconazole resistance. If you are taking fluconazole tablets regularly as a preventative measure -- which is more common when yeast infections affect the mouth or throat rather than the vagina -- your HIV doctor will want to check for interactions between fluconazole and anti-HIV medications.
Bacterial vaginosis is usually treated with the antibiotic metronidazole (Flagyl). It can make you viciously sick if you drink alcohol while taking it, so try to avoid alcohol while taking this drug and for two to three days afterwards. If this is impossible, ask about the antibiotic clindamycin. Be aware that metronidazole, clindamycin and some other antibiotics can disturb the natural balance of bacteria in the vagina and may increase the risk of yeast infections. Clindamycin can also cause diarrhea, especially if you are already having a problem with this due to anti-HIV medications.
Herpes simplex virus outbreaks are often more severe, last longer and may recur more often among people with HIV. I send my patients home with antiviral medications prior to their outbreaks so they can begin their meds the moment they spot a new lesion or feel the tingling that precedes one. This really helps get painful flares under control.
Two herpes medications, acyclovir (Zovirax) and valacyclovir (Valtrex), may increase levels of tenofovir (Truvada and in Atripla), so your doctor should monitor you for adverse effects if you are taking either of these drugs for a long time. They can also affect kidney health.
Cheryl Collier, R.D., Clinical Dietitian, Oak Tree Clinic, Vancouver
Reams of information exist in the media about using the "Candida diet" to prevent or treat yeast infections. Advocates of this high-vegetable, high-protein diet advise people to avoid simple sugars as well as other foods including some dairy products, fruit, starchy vegetables and starchy foods, such as gluten-containing grain products (anything made from wheat or related cereals such as barley and rye). Evidence does not show that cutting out all these different foods can prevent or treat yeast infections, though limiting added sugars and refined carbohydrates is always a healthy practice. I encourage women with HIV to consider that a balanced diet is important for getting all essential nutrients needed for good health.
Women with uncontrolled diabetes are at increased risk for developing recurrent yeast infections. For this reason and others, it is important to get diabetes under control, which includes working closely with a doctor. HIV-positive women with uncontrolled diabetes are encouraged to eat balanced regular meals, choose higher-fibre foods and limit refined carbohydrates to help manage their blood sugars. This, along with other strategies, such as regular physical activity and taking diabetes medications as prescribed, will hopefully help keep blood sugars under better control and decrease the risk of recurrent yeast infections.
There is more and more interest in the effect of probiotic preparations on preventing or treating yeast infections and treating bacterial vaginosis. Although this is a growing area of research, not enough evidence currently exists to show that they do this. It is a difficult area to research because studies are often small and the probiotic treatments being studied can be quite different. More high-quality research is needed to better understand the role of probiotics in treating vaginal infections.
Finally, women going through menopause should drink enough fluids to stay well hydrated and help ward off vaginal dryness. This applies to all women, but it bears repeating because it is so important and yet easily forgotten during a busy day. Talk with a healthcare provider, such as your family doctor, nurse or gynecologist, if you have vaginal dryness.
Some herbs interact with prescription medicines, including anti-HIV drugs and over-the-counter products. This can change the medication's effectiveness or intensify its side effects. Be sure to let your doctor know about all the herbs, supplements and other complementary therapies you take.