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Menopausal hormone therapy for women living with HIV
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Lancet HIV -Elizabeth Marie King, Jerilynn C Prior, Neora Pick, Julie van Schalkwyk, Mary Kestler, Stacey Tkachuk, Mona Loutfy, Melanie C M Murray
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Summary
People living with HIV are ageing, and a growing number of women living with HIV are entering menopause. Women living with HIV commonly have bothersome vasomotor symptoms and onset of menopause at earlier ages; both factors go on to affect quality of life and systemic health. Vasomotor symptoms and early menopause are both indications for menopausal hormone therapy; however, current evidence suggests that this therapy is seldom offered to women living with HIV. Additionally, women living with HIV have several risks to bone health and are likely to benefit from the bone-strengthening effects of menopausal hormone therapy. We present an assessment of the benefits and risks of menopausal hormone therapy in the context of HIV care and propose a practical approach to its prescription. If considered in the appropriate clinical context with discussion of risks and benefits, menopausal hormone therapy might provide substantial benefits to symptomatic menopausal women living with HIV and improve health-related quality of life.
Introduction
Available and effective antiretroviral therapy (ART) has caused a shift in the age demographic of women living with HIV. As a result, an increasing number of these women will go through menopause, defined as at least one year without menstruation with no other obvious pathologic or physiological cause.
Current evidence suggests that women living with HIV experience a high burden of hot flushes and night sweats (collectively called vasomotor symptoms), and are at increased risk of primary ovarian insufficiency (menopause at an age younger than 40 years) and early menopause (at an age younger than 45 years).
Although premature reproductive ageing and severe vasomotor symptoms are guideline-approved indications for menopausal hormone therapy (MHT), this therapy is seldom offered to women living with HIV even in the setting of comprehensive, available health care.
As we see growing numbers of women living with HIV entering their symptomatic midlife, it becomes increasingly important to optimise clinical care for these women, including consideration of MHT when appropriate. Herein, we review the potential benefits and risks of MHT in the setting of HIV to open the dialogue about treatment of symptomatic women living with HIV and those experiencing premature reproductive ageing (panel 1).
Panel 1
Overview of MHT in women living with HIV
•MHT is effective and safe for the treatment of problematic night sweats and hot flushes (collectively referred to as vasomotor symptoms) in healthy women early in menopause (ie, 1 year or more and less than 10 years without menstrual flow)
•Menopausal women living with HIV frequently have vasomotor symptoms and, even when highly symptomatic, are rarely offered MHT
•Primary ovarian insufficiency (ie, menopause onset at an age younger than 40 years) and early menopause (ie, menopause onset at an age younger than 45 years) are more common in women living with HIV—these women are missing years of ovarian hormones and most likely will benefit from MHT
•Increasing life expectancy for women living with HIV means more women are entering midlife and experiencing symptoms that negatively affect quality of life
•Pragmatic controlled trials of MHT with women living with HIV as partners and participants are urgently needed to assess effectiveness and safety
MHT=menopausal hormone therapy.
Panel 2
Contraindications to menopausal hormone therapy
General contraindications
•Unexplained vaginal bleeding
•Acute or severe liver dysfunction
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History of stroke
•Coronary heart disease
•Dementia
•Hypertriglyceridaemia (more than two times upper limit of normal)
•Oestrogen-dependent cancer
•High venous thromboembolism risk
Conclusion
Worldwide HIV care is shifting towards a focus on preserving health-related quality of life during ageing, as evidenced by the proposal to add quality of life to the 90-90-90 UNAIDS targets.
Menopausal women living with HIV are an important part of the HIV community; these women have a high prevalence of moderate to severe vasomotor symptoms and early menopause, both of which can affect the quality of life. Due to its controversial past and the collective lack of training in its use, MHT is rarely considered for women living with HIV, despite this group being disproportionately affected by health risks that such treatment will most likely benefit. Further studies are needed to address several knowledge gaps that remain about MHT use in women living with HIV (panel 3). However, while awaiting appropriate studies, providers should be ready to engage in candid conversations about MHT with menopausal women living with HIV, covering its benefits, risks, and unknowns. Neglecting to consider an important management option such as MHT in the appropriate clinical context might lead to missed opportunities to improve health-related quality of life for women living with HIV during this important and often symptomatic midlife transition.
Panel 3
Knowledge gaps and areas of future research for use of MHT in women living with HIV
•Current rates of use, adherence, and reasons for discontinuation of MHT among women living with HIV
•Rates of adverse events, especially coronary artery disease, venous thromboembolism, cerebrovascular disease, and breast cancer for women living with HIV who use MHT
•Effect of MHT on quality of life and bone health for women living with HIV
•Pharmacokinetic and pharmacodynamic studies of drug interactions between antiretroviral therapy and MHT of different formulations (oral, transdermal, and topical; biosimilar and synthetic)
•Evaluation of values and preferences of women living with HIV regarding symptomatic relief compared with the risks of adverse events with MHT
•Prevalence of hormonally confirmed early menopause in women living with HIV
MHT=menopausal hormone therapy.
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