Menstrual Changes

For many people who have a menstrual cycle, their period occurs monthly at a predictable time, lasts for the same amount of time from one month to the next and has with a flow that they come to recognize as typical for them. Others do not have a particularly regular cycle and this irregularity is their “norm.” Most tend to develop a good sense of what is normal in terms of their menstrual cycle and can identify changes. At various times in their lives, most people with a menstrual cycle experience changes in their cycle, regardless of whether they are HIV-positive or not.

Some of these changes are considered “normal,” signalling pregnancy, menopause (the point in later life when your periods stop permanently and you are no longer able to become pregnant) or perimenopause (the period prior to menopause when changes occur in your reproductive hormones and your body transitions into menopause).

But sometimes, some changes are unexpected and may indicate a health problem. Periods may become irregular, occurring either more or less frequently than usual, and are sometimes skipped entirely. Or the menstrual flow changes, with either heavier or lighter bleeding during some periods. The amount of bleeding may not be consistent from one period to another. Some people who are not pregnant (or going through perimenopause or menopause) may have no period for a number of months, a condition known as amenorrhea. Others find that their premenstrual symptoms become more difficult than they were previously.

While many cisgender (non-transgender) women, as well as trans men who are not on testosterone therapy, bleed during their periods, some trans women on hormones experience a “bloodless period” characterized by regular monthly abdominal pain, cramping and other symptoms. Though the cycles of trans people are poorly understood, information in this chapter on premenstrual symptoms may be useful to you.

Early studies of HIV in cisgender women reported a number of differences between the menstrual cycles of HIV-positive and HIV-negative women. More recent and better designed studies have more clearly identified those menstrual irregularities tied directly to HIV status. These studies seem to show that although menstrual irregularities occur with HIV infection, they are common in the general menstruating population overall, leading to the conclusion that HIV may have less impact on menstruation than originally thought.

Studies report no significant differences in the rates of excessive menstrual pain (also called dysmenorrhea), the development of perimenopausal symptoms or the development of early menopause. However, some studies have shown an increased likelihood of missed periods (amenorrhea) and delayed periods (oligomenorrhea) in women whose HIV disease has advanced because they are not on antiretroviral therapy. In particular, one large study found that cisgender women with CD4 counts below 200 were about 50 percent more likely to have irregular cycles with 90 days or more between periods.

Reporting any menstrual changes to your doctor is very important since these changes can indicate health problems related to the reproductive organs, including cervical dysplasia (early changes in cervical cells that can lead to cervical cancer), pelvic inflammatory disease or endometrial conditions. Of course, menstrual changes can also indicate pregnancy. During pregnancy, unexpected bleeding could indicate miscarriage.

Menstrual irregularities can occur as a result of various sexually transmitted infections or almost any serious infection, HIV-related or otherwise. Some people with HIV develop low levels of platelets (thrombocytopenia), which can contribute to heavier than normal menstrual bleeding.

Many other health issues can contribute to menstrual irregularities, including stress, eating disorders, hormones (not only changes in estrogen and progesterone but also in thyroid, pituitary and adrenal hormones), excessive weight loss, excessive exercise or the presence of other chronic diseases, including diabetes, kidney or liver disease and inflammatory bowel disease.

Many medications can cause menstrual changes, including various anticoagulants (blood thinners), narcotic pain medications, methadone/heroin, corticosteroids and others. Some of the early protease inhibitors (high-dose ritonavir (Norvir), saquinavir (Invirase) and indinavir (Crixivan)) have also been associated with increased menstrual bleeding. Because Aspirin can thin the blood, making it less likely to clot, long-term use of high doses of Aspirin can contribute to longer, heavier periods. Some herbal supplements can copy or mimic the effects of estrogen and taking these can also result in menstrual irregularities.

A Canadian study found a higher risk of magnesium deficiency in people with HIV disease. Magnesium deficiency can cause many problems, including a worsening of several premenstrual symptoms. In turn, some menstrual problems can worsen other HIV-related conditions. For example, HIV-positive people have a high incidence of anemia (low red blood cells), and the risk is higher during menstruation because the loss of blood during this time is added to other contributing causes. Since there is already an increased risk for anemia in HIV disease, heavy bleeding should be discussed with your doctor as it can further worsen anemia. More information on anemia is found in the Fatigue section.

Treatment for menstrual irregularities varies depending on the problem and what is causing it. In people with untreated HIV disease who are not yet on antiretroviral therapy, beginning effective treatment can be very important to raise CD4 counts. Lower counts have been associated with higher risk of menstrual irregularities. Beginning antiretroviral therapy with any level of wasting will help restore weight, which may help restore normal periods.

The bottom line is that changes in your menstrual pattern should always be discussed with your doctor so appropriate tests can be done to determine the cause.

Low levels of the hormone testosterone have been linked to HIV-related wasting syndrome. Although testosterone is usually thought of as a male hormone, cisgender women’s bodies also produce it in smaller amounts. Researchers tested a daily testosterone skin patch on a small group of cisgender women with wasting syndrome and low testosterone. The dose used was just enough to bring their testosterone levels up to normal. Six of the women had no menstruation before they took part in the study. After 12 weeks of treatment, periods returned in five of the six women.

For irregular periods, the use of birth control pills to help restore regularity and reduce heavy bleeding may be recommended. Hormone replacement therapy is sometimes recommended during perimenopause or early menopause, especially when symptoms are very severe. Because of concerns about the possible risks of cancer with long-term hormone replacement therapy, short-term use for the specific relief of symptoms is preferred. Any hormone replacement therapy should be thoroughly discussed with your doctor. Possible interactions with other medications also need to be discussed.

Physical and emotional symptoms can develop during the week leading up to your period and can continue throughout it. Although almost all people who menstruate experience some degree of premenstrual symptoms, many people with HIV have reported increased and more intense symptoms. There are many remedies for relief of premenstrual symptoms; you may have to try several different ones before finding something that works for you.

The good news is that it is possible to greatly decrease or even eliminate premenstrual symptoms. Whatever approaches you decide to take, it is helpful to keep a diary of how you feel, both emotionally and physically, before you start anything new and for several months afterward. This can help tell you what’s working and what isn’t so you can choose the elements of your approach more wisely.

Regular physical exercise can help to relieve premenstrual symptoms. A regular exercise program is an important part of a healthy lifestyle; if exercise is not currently part of your lifestyle, knowing that it can help reduce premenstrual symptoms can be a reason to add it.

Many experts recommend cutting down or cutting out caffeine, sugar, salt and alcohol to help with premenstrual symptoms. Reducing salt in the diet has been shown to help cut down on water retention and the sensation of being uncomfortably bloated. It can be difficult to find salt-free foods, but by cooking from scratch, looking for salt-free foods and reading the labels on food packages for sodium content, it is possible to reduce the daily salt content of your diet.

Cutting back on caffeine can also help since caffeine can increase the anxiety and irritability associated with premenstrual symptoms. Remember that caffeine is found not only in coffee and tea, but also many soft drinks, chocolate and many over-the-counter medications. Alcohol has also been shown to worsen headaches, fatigue and depression in people with premenstrual symptoms. If alcohol is part of your lifestyle, cutting it out during the premenstrual week can be helpful.

Research has found that consuming a combination of carbohydrates results in an increase in serotonin (the brain’s “happiness” chemical) and can help to reduce tension, depression and anger in people suffering those premenstrual symptoms. Any combination of foods that raises the blood levels of tryptophan will work because tryptophan stimulates the production of serotonin. High-carbohydrate foods, such as whole-grain toast or hot cereal, as well as protein foods that are high in tryptophan, such as dairy products and turkey, will raise serotonin levels.

Adding carbohydrate-rich snacks for a few days before or during your period can sometimes help lessen the emotional distress that can accompany periods. However, if you add these carbs day after day, weight gain can occur unless you increase your level of exercise. Don’t forget to speak to your doctor about persistent emotional problems and safe ways of finding relief from them.

Several micronutrient supplements can be helpful with premenstrual symptoms.

Magnesium can help some people reduce or eliminate painful cramping. It can also be useful to counter irritability and moodiness. A safe dose to start with is 250 to 350 mg per day. Higher doses can cause diarrhea, but may be needed for effective relief. Magnesium glycinate may be better tolerated than other forms.

For painful or swollen breasts/chest, vitamin E is often very useful. A daily dose of 800 to 1,200 IU taken the week before your period starts and during your period may reduce symptoms. The dosage required to counter these symptoms varies from person to person, so speak to a naturopathic doctor. Be sure your supplement contains the full range of compounds (called mixed tocopherols) that belong to the vitamin E family.

The supplement 5-hydroxytryptophan (5-HTP) is related to tryptophan (mentioned above under “Exercise and diet”) and converts directly to serotonin. See Sleep Problems for a discussion of 5-HTP. It can help relieve the emotional symptoms of the premenstrual period. It is important to take 5-HTP with vitamin B₆ because this vitamin is deficient in many people with HIV and is used to convert 5-HTP to serotonin. Many 5-HTP products contain vitamin B₆. However, 5-HTP should not be taken by people also taking medicines for treating depression or anxiety.

A daily supplement of vitamin B₆ can help reduce water retention and bloating. It should be taken along with a B complex supplement to help keep B vitamins in balance. It also seems to help reduce moodiness associated with premenstrual symptoms.

Gamma-linolenic acid (GLA), found most cheaply in borage oil supplements as well as in evening primrose oil supplements, may help with breast/chest pain, bloating and emotional symptoms such as irritability and depression. A dose of 240 mg, twice daily, is a common recommendation from naturopathic doctors to reduce premenstrual symptoms.

According to a 1991 study, women who consumed 1,300 mg of calcium daily in foods like milk or yogurt reported an easing of symptoms such as water retention and moodiness. Since the average person gets only 550 mg daily from their diet, temporary supplementation may be useful. However, before taking calcium supplements, it may be best to try and eat more calcium-rich foods. If this is too difficult, speak to your doctor about your calcium needs.

Herbs like black cohosh, raspberry root or rue can help relieve premenstrual symptoms in some people. However, some herbs can interact with various medications. Before starting any herbal therapies, consult a naturopathic doctor or herbalist in addition to your doctor and a pharmacist highly knowledgeable about HIV.

Naproxen (Aleve, Anaprox), mefenamic acid (Ponstan) and ibuprofen (Advil, Motrin) are anti-inflammatory drugs that relieve cramps and can reduce premenstrual symptoms. They are available over the counter from your pharmacist. Talk to your doctor about using these sorts of drugs, especially if you are taking tenofovir (Viread and in Truvada, Atripla, Complera and Stribild) as there is a risk of kidney injury.

As well, several prescription drugs are sometimes recommended for severe emotional symptoms associated with your period. Some antidepressants can improve mood swings, irritability and depression by boosting serotonin levels in the brain. These medications have the potential for serious side effects so be sure to discuss your options thoroughly with your doctor.

Make sure you discuss your use of any products, including multivitamin-mineral supplements, herbal and other complementary therapies, over-the-counter products and prescription drugs, with your doctor and pharmacist before taking them. Some products can interact with HIV medications and lead to increased side effects or cause the antiretroviral drugs to be less effective. Mineral supplements, including calcium and magnesium, may need to be taken separately from certain drugs. Speak with your pharmacist and doctor to understand how best to take all your medications and health products.