Many HIV+ women experience menstrual problems including:

• Irregular periods
• Abnormal bleeding (lighter or heavier)
• Missed periods
• No period for more than 90 days (amenorrhea)
• More severe premenstrual syndrome (PMS)

Studies have found that menstrual irregularities are more common if you have a low CD4 cell count, a high viral load, or are significantly below your ideal body weight.

As HIV progresses, changes in your immune system can affect the way your body makes and maintains levels of different hormones including testosterone, estrogen, and progesterone. Slight changes in the amount of one can affect the levels of all the others. Altered levels of estrogen or progesterone could result in a variety of menstrual symptoms for HIV+ women.

In the course of HIV, many women lose weight, become anemic (have decreased red blood cell counts), or develop nutritional problems. Each of these conditions can also affect the hormonal systems that regulate your menstrual cycle.

Untreated infections in your vagina or cervix can sometimes lead to heavy bleeding, bleeding between periods, or bleeding after sex. Pay attention to this type of bleeding, as it may signal a complication (like pelvic inflammatory disease or PID) that can threaten your health.

Bleeding between periods is one of the only signs of high-grade cervical dysplasia—a condition that can lead to cancer and requires treatment. If you have heavier bleeding or spotting, it’s important to act quickly: See your gynecologist (GYN) and have a full exam.

Certain drugs can also interfere with menstrual cycles. If you use heroin, opiates, or amphetamines you may miss periods or stop having them altogether.

Marijuana use (more than several joints a day) may also result in a missed period. Methadone and cocaine don’t seem to have the same effect. However, many women using drugs lead stressful lives, don’t eat regularly, and may not have access to nutritious foods. In the context of cocaine use, missed periods may be the result of malnutrition or severe weight loss.

Some medications can throw off your menstrual cycle. If you’re taking Megace, Depo-Provera, or progestin-dominant birth control pills, watch out for heavy or prolonged bleeding.

Yes, but research is lagging behind the experiences of women in this area. Many of the original trials that led to the approval of the first HIV drugs enrolled very few women, and the women in those studies were not asked about their periods. As a result, until several years ago, there were virtually no clinical data on which drugs cause menstrual side effects.

In 1999, a small study suggested that women using Norvir (ritonavir), or the combination of Norvir and Fortovase (saquinavir) could be at greater risk for anemia due to excessive menstrual bleeding.

Researchers have since started using newer technologies to study how drug levels of protease inhibitors change throughout the course of the menstrual cycle. This will give us important information about how HIV therapy and the menstrual cycle affect one another.

In the meantime, keep in mind that the lack of research doesn’t make your symptoms any less real. If you’re taking HIV therapy, watch out for any changes in your bleeding, and be sure to tell your doctor if you have heavier, prolonged, or more frequent periods.

Because there are so many possible reasons for menstrual symptoms, it’s very important to have a thorough evaluation.

If you miss two or more periods in a row, see your GYN for a pelvic examination and blood tests to determine if you have a common infection (like chlamydia) that can affect your reproductive tract.

You may need your hormone levels checked to determine if low estrogen or too much progesterone is causing a particular menstrual symptom.

Your doctor will want rule out the following factors as the reason for missed periods:

• Ovarian cysts
• Pregnancy
• Opportunistic infections
• Unwanted weight loss
• Interactions with certain drugs
• Different medications you may be taking
• Menopause

If heavy bleeding or bleeding between periods is a problem, your doctor should check your platelets and use either a sonogram or colposcopy to check for PID, ovarian cysts, or tumors.

1. Treat any underlying infections, cervical disorders, or cysts
2. Address nutritional deficiencies, anemia, and unexplained weight loss
3. Review all the drugs you are taking, including medications for HIV and HIV-related conditions, street drugs, and birth control pills, with your health care providers
4. Consider birth control pills or hormone replacement therapy (HRT) to restore balance to your hormones and regulate menstrual cycles, but be careful of interactions with HIV drugs
5. Discuss non-prescription remedies with your health care providers:
   Soy: For general symptom management
   Omega-3 fatty acids: For menstrual cramps, bloating, swollen breasts, and mood changes
   Magnesium: For cramps and irritability
   Vitamin B complex or calcium: For bloating
   Vitamin E: For hot flashes or swollen breasts
6. Adequate sleep, regular exercise, acupuncture, and/or yoga may provide some relief from pre-menstrual symptoms

Even though menstrual problems are common, suffering through them is not a normal part of HIV. In most cases, it’s possible to trace individual menstrual symptoms back to a root cause and treat or manage the problem.

Even if you’re not taking HIV therapy, you may want to keep track of the start/end dates of your periods each month. Get regular GYN exams and Pap smears a part of your routine health care and report any changes in your menstrual cycle to your health care providers.

1

Garcia, et. al. (2002). Treatment issues for women. AIDS Community Research Initiative of America. p. 3-13, 18-19: Retrieved July 2003 from http://www.criany.org/treatment/women.pdf