Menstruation and HIV: Amenorrhea risk is high, but modifiable in women

Amenorrhea, defined as no menses for at least 1 year, is relatively common among women with HIV, and it is associated with several modifiable factors, including substance use and food insecurity, according to study results published in Open Forum Infectious Diseases.

Researchers analyzed cross-sectional data from 2 prospective cohort studies (the Children and Women: AntiRetroviral Therapy and Markers of Aging [CARMA] and British Columbia CARMA-CHIWOS Collaboration [BCC3] studies) to determine whether women with HIV have higher lifetime frequencies of amenorrhea and whether this is independently related to HIV and/or other biological or psychosocial variables. Women aged 16 and older without a history of anorexia or bulimia nervosa who were not pregnant or lactating in the previous 3 months were eligible for inclusion. Amenorrhea was defined by self-reported history of no menstrual flow for at least 12 months postmenarche, not attributable to pregnancy, lactation, medication, or surgery, nor early menopause or premature ovarian insufficiency.

Three items from the Household Food Security Survey Module were used to measure current food insecurity, while the 6-item post-traumatic stress disorder (PTSD) checklist was used to evaluate current PTSD. Past and current violence (ie, physical, sexual, verbal, and controlling violence) was assessed using 4 items from the BCC3 questionnaire. Biopsychosocial covariates of amenorrhea were examined using univariable and multivariable logistic regression models.

A total of 317 women with HIV (median age, 47.5; White, 37.6%; median body mass index [BMI], 26.7 kg/m²) and 420 women without HIV (median age, 46.2; White, 46.3%; median BMI, 25.8 kg/m²) were eligible for study inclusion. More women with vs without HIV reported ever using substances (P <.001) and ever smoking tobacco (P <.001).

Amenorrhea was present in 24% of women with HIV and 13.3% of those without. Women with amenorrhea (BCC3 participants, 70.5%; CARMA participants, 29.5%) were more likely to be White, have a current household income of more than $20,000 CAD/year, and have a current or past history of smoking and substance abuse. BCC3 vs CARMA participants were significantly older (median age, 47.6 vs 44.8 years) and more likely to have ever used opioids (31.8% vs 20.1%).

The following covariates were found to be associated with greater odds of amenorrhea in univariate analyses:

• Living with HIV (odds ratio [OR], 2.05; 95% CI, 1.40-3.01);
• Older age (OR, 1.02; 95% CI, 1.01-1.04);
• White ethnicity (OR, 1.50; 95% CI, 1.02-2.19);
• Income (>$20,000 CAD/year; OR, 2.02; 95% CI, 1.37-2.97);
• Smoking (OR, 3.73; 95% CI, 2.44-5.87); and
• Substance use (OR, 7.77; 95% CI, 5.03-12.3).

In multivariable analyses, independent covariates of amenorrhea included:

• Living with HIV (OR, 1.70; 95% CI, 1.10-2.64);
• Older age (OR, 1.01; 95% CI, 1.00-1.04);
• White ethnicity (OR, 1.92; 95% CI, 1.24-3.03); and
• Substance use (OR, 6.41; 95% CI, 3.75-11.1).

Among participants in the BCC3 study, current food insecurity was also significantly associated with greater odds of amenorrhea (OR, 3.86; 95% CI, 2.22-6.22).

Study limitations included the inconsistent measurement of some variables, potential recall bias, and missing data on the use of androgenic drugs, antipsychotics, and other medications that could cause amenorrhea.

“Care providers should regularly assess women’s menstrual health and advocate for actionable socio-structural change to mitigate risks,” the researchers concluded.

By Paul Basilio

References:

Swann SA, King EM, Pang D, et al. Associations of early prolonged secondary amenorrhea in women with and without HIV. Open Forum Infect Dis. Published online August 26, 2024. doi:10.1093/ofid/ofae493