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Scientists at the University of British Columbia and the Oak Tree Clinic in Vancouver collaborated on a study to explore the issue of premature cessation of menstruation during reproductive years—a condition called amenorrhea. The study enrolled both HIV-positive and HIV-negative women of similar sociocultural background. The scientists defined amenorrhea as a past or present lack of periods for more than one year that occurred before the age of 45 and was unrelated to pregnancy, breastfeeding, surgery or use of hormonal contraception. Amenorrhea is different from menopause.
The scientists collected and analysed data from 258 women and found that prolonged amenorrhea occurred in 21% of HIV-positive and 9% of HIV-negative women. Furthermore, amenorrhea was linked to significantly reduced bone density in the hips. The scientists concluded that prolonged amenorrhea is another risk factor for osteoporosis in HIV-positive women. Based on their findings, they provided recommendations to reduce the risk of amenorrhea in this population.
Scientists recruited 129 HIV-positive and 129 HIV-negative women for this study. All participants were adults and completed detailed surveys about menstrual patterns, bone health and other issues. They also underwent low dose X-ray scan (DEXA) to assess bone density.
The average profile of all the women upon entering the study was as follows:
HIV-specific measures:
There are two main types of amenorrhea:
The Vancouver scientists focused on secondary amenorrhea, which we simply refer to as amenorrhea in this CATIE News bulletin.
Key findings:
The proportions of women with fractures were as follows:
The scientists noted that some risk factors for amenorrhea—such as very low or very high body mass index (BMI), severe liver injury, exposure to anti-psychotic medicines—were similarly distributed between the HIV-positive and HIV-negative groups. Therefore, these factors were unlikely to be the major drivers of the difference in rates of amenorrhea seen in this study.
However, the scientists stated that HIV-positive women with amenorrhea “had significantly higher” rates of the following possible amenorrhea risk factors:
The scientists stated that the use of opioids “was particularly high” among HIV-positive women in the study. For instance, “63% of [HIV-positive women] experiencing prolonged amenorrhea indicated past or present opioid use/therapy compared to 22% of those without [amenorrhea].”
As part of the study, women were asked what they thought caused them to experience amenorrhea. Some of their answers were as follows:
Lab tests of the blood samples from HIV-positive women who reported amenorrhea found that only four HIV-positive women had hormonal levels suggestive of early menopause or premature failure of the ovaries (a level of follicle-stimulating hormone of 25 IU/L or greater). Thus, opioids likely contributed to the development of amenorrhea.
Positive factors that help maintain or even increase bone density include supplementation with calcium and vitamin D and hormone replacement therapy. Other factors can have a negative effect, reducing bone density, such as the following: use of corticosteroids, smoking and use of the anti-HIV drug tenofovir DF (in Atripla, Complera, Stribild, Truvada and generic formulations). The scientists found no significant differences in the distribution of these factors among HIV-positive women with or without amenorrhea.
Based on the data they collected as well as other studies with HIV-positive women, the B.C. scientists stated that there may be multiple factors affecting the hormonal health of women in the present study. They singled out the following factors that likely increased the risk of amenorrhea:
A subgroup of women—those who have or had amenorrhea—are at high risk for bone thinning, particularly in the hips, and therefore they are also at risk for fractures. The scientists described the degree of bone thinning in HIV-positive women who have or had amenorrhea as “profound.” Such a degree of bone thinning has been historically linked to a 2.6-fold increased risk of fracture in HIV-negative women (data for large numbers of HIV-positive women are not available). HIV-positive women would have at least a similar risk of fractures, perhaps even higher given that risk factors for bone loss are generally greater among people with HIV.
The present study was cross-sectional in design, which means that data were captured at one point in time. The study was well designed with a comparison group of women who were socially and culturally similar to the HIV-positive women. Furthermore, the women in this study are representative of the distribution of HIV among women in British Columbia.
The scientists stated that HIV-positive women who have or had amenorrhea “may benefit from earlier fracture risk investigation than is currently recommended [after menopause or a new fragility fracture]. Prompt recognition of abnormally low bone density may allow early initiation of effective therapy [among women who have or had amenorrhea] or preventative measures,” such as the following:
In addition, the scientists recommended the “usual strategies” to prevent further bone loss, including the following:
There are also medicines that can be prescribed to reduce the loss of bone density.
Resources
Irregular or absent periods – Society of Obstetricians and Gynecologists of Canada
Amenorrhea – Hormone Health Network (available in English only)
B.C. study finds that HIV-positive women are likely to have other health conditions – CATIE News
Traditional risk factors have a big impact on bone thinning in HIV-positive people – CATIE News
Canadian study examines why some women fall out of the HIV care cascade – CATIE News
Comparing substance use patterns among women in Canada – CATIE News
Delays in cervical cancer screening among some HIV-positive Canadian women – CATIE News
—Sean R. Hosein
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