Note: in this article, “women” refers to cisgender women — those who identify as women and were assigned female sex at birth. Menopause also affects transgender men and non-binary people, but published research on the menopause experience has included only cisgender women participants.March 18, 2022 — Gina Brown was boarding an early-morning flight in 2016 when she suddenly started to overheat.“As soon as I stepped on the plane, I immediately was drenched in sweat,” she says.Not knowing what to do, she stood still until a fellow female passenger noticed her alarm and asked a flight attendant to grab her a cup of ice.“Is this the first time this has happened to you?” the woman asked, and Brown nodded.“It’s called a hot flash,” the woman continued, “and you’re going to be OK.”As soon as Brown returned from her trip, she visited her doctor for bloodwork and learned that that her hormone levels were decreasing.“I knew something was going on, but [my provider and I] didn’t have a conversation about menopause,” she says. Brown, 56, has been living with HIV for nearly 28 years and is part of a growing group of women with HIV now entering menopause. In 1996, a person diagnosed with HIV at 20 could expect to live only to 39. Because of antiretroviral therapy (ART), an HIV diagnosis is not nearly so dire. Now, someone with HIV who sticks to their treatment could live nearly as long as anyone else.For women with HIV, this means going through menopause. Though this transition can be challenging for any woman, having menopause with HIV adds another level of complication. On top of staying with daily ART plans, they must also deal with the hormone changes of menopause and the symptoms that come with it. And the limited research in this area suggests that women with HIV and their doctors may not be prepared.“Those of us long-term survivors who have been around for a while never expected to be here, and I don’t think providers or the health care system expected us to be here,” says Vickie Lynn, PhD, who is 56 and has been living with HIV for 37 years, since an AIDS diagnosis in 1991. Her work focuses on health care for people with HIV. “So now that we’re here, I don’t know that we have enough information or research to inform some of our treatment options,” she says.Instead, these women are met with a series of unknowns due to limited studies and conflicting findings.Earlier Menopause?The start of menopause can be difficult to determine in women living with HIV, says Sara Looby, PhD, a researcher at Massachusetts General Hospital in Boston and an assistant professor of medicine at Harvard Medical School. Her research focuses on metabolic disorders, including bone loss, cardiovascular disease risk, and menopause in women living with HIV.This population is at an increased risk for what’s known as amenorrhea, or missing menstrual periods, due to both behavioral and clinical factors, and sometimes this is mistakenly assumed to be menopause, Looby says.A history of smoking, low weight, methadone use, or use of other drugs is common in women with HIV and can lead to missed periods.Some factors specific to HIV — including a low count of one type of white blood cell and an AIDS diagnosis — have also been linked to amenorrhea. This is likely why studies that look at the average age that women with HIV reach menopause can end up with different results.Some studies suggest that women with HIV tend go through menopause 3 to 5 years earlier than other women. Other studies suggest no difference in the age menopause begins.But how to determine when menopause begins varied from study to study, Looby says. Future research needs to consider patients’ complete menstrual and reproductive history, as well as medical, social, and behavioral histories, she says, so that the findings are consistent.If menopause starts earlier in women with HIV, there could be more health concerns. Estrogen regulates bone mass, and some research suggests the hormone may help protect the heart. Estrogen is also thought to increase production of the neurotransmitter serotonin, which could affect mood and thinking skills. Women with HIV are already at higher risk for bone loss, heart disease, and feelings of depression, Looby says, and as estrogen levels fall during menopause, these conditions may worsen.More Frequent and Severe Menopause Symptoms?Women with HIV may not only go through menopause earlier, but their symptoms may also be more frequent and more severe. In a 2017 study of HIV-positive and HIV-negative Nigerian women, those with HIV had more menopause symptoms overall and were three times as likely to report severe symptoms, compared to women without HIV. A 2005 study done in New York City found HIV-positive women were 24% more likely to report menopause symptoms, compared to HIV-negative women in the study. Looby’s own research has also found a similar pattern. In a study comparing 33 women with HIV to 33 women without HIV — all close to menopause and matched for age, race, body mass index, and menstrual patterns — women with HIV reported more severe hot flashes and more days with hot flashes. These women also said their hot flashes interfered to a much greater degree with daily activities and quality of life, compared to those in the study without HIV. But studies of women with HIV who are entering menopause are rare, and most include only small numbers of women. As a result, many women with HIV do not know what to expect. “I always say, ‘I wish somebody would do some real research on HIV and menopause, because I want to know if it is worse for us or if it is same,” says Brown, the director of strategic partnerships and community engagement at the Southern AIDS Coalition in Powder Springs, GA, outside Atlanta. “I would think it’s worse for me.”More frequent and severe symptoms can have other effects, with some evidence suggesting that women with HIV and severe menopause symptoms are less likely to stick to their HIV treatments.“There’s a clear picture emerging that menopausal symptoms in this group really matter,” says Shema Tariq, PhD, an HIV doctor-scientist at the University College London Institute for Global Health in England. “They really impact women’s well-being, as well as impacting their ability to look after their long-term condition.”Providers Wary of Treating Menopause in Women With HIVThe little research we do have about women with HIV who are in menopause suggests they could greatly benefit from the same kinds of treatment offered women without HIV, including hormone replacement therapy (HRT). Women with HIV regularly have night sweats and hot flashes during the menopause transition and may have more severe symptoms than women who don’t have the virus. If women with HIV are more likely to enter early menopause (defined as entering menopause before the age of 45), then this group meets two conditions for hormone replacement therapy. Despite the potential benefits of HRT to women with HIV, some studies suggest not enough women are getting it. In Tariq’s study, which explores how menopause affects more than 800 women living with HIV, only 8% of respondents said they used hormone replacement therapy. In a Canadian study that has not yet gone through peer review, 11.8% of women who are transitioning to menopause and women who have already been through menopause reported ever using HRT, about half the rate of women in North America without HIV. Doctors’ discomfort with managing menopause-related care in women with HIV is one reason for such low use of hormone therapy, Tariq says. In a survey of 88 general practitioners in the United Kingdom, more than 95% said they were comfortable managing menopause in a general population, but just 46% said they felt comfortable managing menopause in women with HIV.Their top concerns included the potential for drug-to-drug interactions between certain HIV drugs and hormone replacement therapy, missing an HIV-related diagnosis, and the risks of menopausal hormone therapy in HIV. Nearly half of respondents said only specialists should be providing menopause-related care for women with HIV.But specialists may also feel conflicted about treating menopause in women with HIV, says Tariq.“If you’re looking at people who manage HIV, you’re looking primarily at infectious disease physicians and HIV physicians. We’re not trained as gynecologists. We’re not used to prescribing HRT,” she says. “And the problem is gynecologists aren’t used to managing HIV. They get nervous about prescribing anything when they see antiretroviral medication [a type of HIV drug] because all that people think of is a drug-drug interaction.”This leaves women with HIV seeking care and treatment for menopause in a difficult situation, where they are “just being ping-ponged around between different health care providers,” says Susan Cole-Haley, 53, an HIV activist in London who has been living with the virus for 23 years. “So many women with HIV have multiple health conditions and multiple health care providers, which can just make it really problematic and really exhausting in terms of getting help.”Many UnknownsProviders may also be uncomfortable with prescribing hormone therapy because of alarming research in the early 2000s that found that hormone replacement therapy increased the risk of breast cancer and heart disease. More recent research found no increased heart disease risk in women younger than 60 or less than 10 years beyond the start of menopause. Still, the “media frenzy” around the early findings “has put off a whole load of patients and a whole load of clinicians from even thinking of HRT,” Tariq says.Providers may be even more hesitant because people with HIV already have a higher risk for heart disease, due to behaviors like smoking as well as HIV-specific factors. (Research has yet to tease out whether these heart effects are a result of the virus, a result of the antiretroviral therapy, or both.) In addition, there have been no studies looking directly at how well, and how safely, hormone replacement therapy works in women with HIV, so providers generally rely on the guidelines for the use of menopausal hormone therapy for women without HIV. While researchers from Canada and the United Kingdom have compiled recommendations for HRT in women with HIV, there is a great need for a large-scale clinical trial to create consistent guidelines, Looby says.While these unknowns do need to be discussed with patients before starting hormone replacement therapy, they should not stop doctors from considering the treatment, says Elizabeth King, MD, of the Women’s Health Research Institute in Vancouver, Canada.“If women are having extremely troublesome symptoms, then withholding therapy that is potentially beneficial because of worries about some of the things we do not know — I don’t know if that is any better,” she says.Many women with HIV may not want to start hormone replacement, as was the case for Lynn.“I’ve taken a lot of medication in my time, and I really try to avoid it as much as possible,” she says.Questions about drug interactions were the main concern for Dawn Averitt, 53, founder of the Well Project, an HIV nonprofit focused on women and girls. Averitt has lived with HIV for 34 years. “What if some of the things that I’m dealing with could be managed by HRT?” she says. “Or what if taking it exacerbates problems in a way that nobody knows to look for?”In this case, providers may work with patients to discuss other treatment options.While some women with HIV may not want hormone therapy, “It’s important that women have that option, and from what we are seeing right now, not a lot of women are even being offered the therapy,” King says.There are non-hormonal treatments for managing menopause symptoms, including common anti-depression drugs and cognitive behavioral therapy, but these also have not been studied specifically in women with HIV.The Path ForwardTariq and Looby agree the next step should be to better engage women with HIV in research and care around their experience with menopause. This includes studies on the symptoms they regularly have and how these symptoms affect their quality of life, including their physical, psychological, cognitive, and social health. These studies could also help researchers and others understand what these women with HIV want for their menopause care, whether that be medication, psychotherapy, and/or peer support groups.Another important factor is increasing education, for patients and health care providers, Looby says. Many women may not know what menopause is, what symptoms look like, and how these hormonal changes can affect their health.If providers keep talking with female patients about menopause throughout adulthood, that can better prepare women for the menopause transition and alert them to common symptoms they may have. There also is a great need to educate doctors and nurses, Looby says.Infectious disease specialists may need more education on menopause management, while women’s health specialists may need more training on managing care for patients with HIV.Ideally, this information could be shared with a team of providers — including infectious disease, primary care, and women’s health specialists — so doctors and other providers can work together to prescribe treatment for women with HIV, Looby says.Lastly, there needs to be more money for research to answer questions related to menopause and HIV, including the age menopause starts in women with HIV, how severe symptoms are, how HIV may affect the transition into menopause and vice versa, and how well treatments work. “If we don’t have funding for these studies, then we won’t have answers to guide clinical care guidelines necessary to support the health, well-being, and quality of life of women with HIV,” Looby says.And the number of women living with HIV entering menopause is expected to keep growing, King says.“It was only a couple of decades ago when women were being told they wouldn’t even live to experience menopause, and now we are at a point where this is the highest proportion of menopausal women ever that we have seen in our HIV clinics,” she says.“It speaks to the success of antiretrovirals,” King says, but that also means identifying new challenges and addressing recognized gaps in care. “We are charting a new course, in some ways,” she says. “There is a lot of work to be done.” .