By Yasmin Osei-Kuffour, Specialist Pharmacist HIV and Sexual Health
Over the past few years we have all seen the difficulties many women have experienced in getting continuous HRT supplies. Following International Women’s Day earlier this month, I wanted to reflect on this important topic and its impact on women living with HIV (WLWH). Women with HIV are at an increased risk of developing age-related co-morbidities compared to HIV-negative women.
Data has shown that awareness of menopause symptoms among WLWH is low and more work is needed to increase access to this group of patients. Reasons for this include patients having difficulty recognising menopause symptoms and managing this alongside their long-term health condition. There is a higher prevalence of menopausal symptoms amongst these women, particularly physical symptoms (hot flushes, joint pain and sleep disturbance). Patients struggling with their symptoms may find it difficult to attend clinic appointments and adhere to their antiretroviral therapy, subsequently leading to poor health.
What do national guidelines say?
As we have an ageing patient cohort, I have encountered several patients where the following factors need to be considered.
National guidelines recommend that all HIV-positive women older than 45 years should have an annual review at their HIV clinic, which should include enquiring about any menopausal symptoms and providing information on treatment options. Those requiring treatment should be managed by their GP, who can liaise with the patient’s HIV clinician/a specialist pharmacist for support.
Women have an increased risk of developing osteoporosis after the menopause, and some HIV drugs such as tenofovir disoproxil are known to reduce bone mineral density. To reduce the risk of fractures, we routinely assess the fracture risk in postmenopausal women and women over 50 years old. Depending on their risk, lifestyle advice can be given or they may need to be switched to medicines with a better bone safety profile.
Menopause is known to increase the risk of heart disease and strokes, through narrowing of coronary arteries due to a reduction in the levels of oestrogen. Patients with a high CVD risk can be optimised to an antiretroviral regimen with lower CVD risk and offered lifestyle advice and medicines for primary prevention, where appropriate.
Hormone Replacement Therapy (HRT)
Oestrogen and progestogen, are the main hormones used in HRT to restore female hormone levels. Transdermal HRT is often preferred due to its lower risk of nausea and blood clots.
Many women have described the effects of HRT as life-changing. It has been shown to relieve most symptoms of the menopause, improve bone density and quality of life. There has been a lot of speculation in the media about its risks. Recent evidence suggests these risks remain small and women should have discussions with their doctor/specialist to support their decision-making. Some antiretroviral regimens may interact with HRT products. The Liverpool HIV Drugs Interaction Checker is a useful resource to check for any potential drug-drug interactions between ART and HRT and specialist HIV pharmacists can also advise on appropriate management.
The British Menopause Society has prescribing guidance on equivalent preparations and information on managing common side effects.
Alternative treatments/lifestyle changes
HRT may not be suitable/effective for everyone, and alternative treatments can be used to help ease symptoms. Some patients may benefit from vaginal oestrogens, which may be used alone or together with HRT to provide relief from local symptoms. Others include muscle strengthening exercises (e.g. dancing, yoga) cognitive behavioural therapy for both mental and physical symptoms and peer support groups where patients can share their experiences with others.
Finally, menopause symptoms can be challenging. Patients may experience a range of symptoms including confusion, anxiety and mood changes. It is important to take time to listen to patients, explore their symptoms and help them make informed choices.
It has been very positive to hear the announcement about the new HRT Pre-Payment Prescription Certificate. This initiative will improve access to HRT for many patients and is a further step in reducing health inequalities in menopause care.
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