Reproductive and sexual health

Menstrual changes are not uncommon in women regardless of HIV status. Often, changes are caused by hormonal variations that occur naturally in most women over time.

Menstrual changes can, however, be caused by HIV, particularly if you have a low CD4 cell count and/or a high viral load. They can also be caused by some antiretroviral drugs. You may experience:

• heavier than usual bleeding
• lighter than usual bleeding
• long breaks between periods
• periods which are more painful than usual
• a worsening of premenstrual symptoms
• irregular or ‘breakthrough’ bleeding
• no bleeding at all
• the onset of menopause at a slightly younger age

Many women report changes in their menstrual cycle when they start HIV treatment although research on this issue is inconclusive. Periods may stop when women have a chronic illness or experience severe weight loss. Women who miss their periods may experience pelvic pain, swollen breasts or hot flushes. The absence of periods can also be caused by other things (not the least of which is pregnancy). Heavy bleeding can occur, which can lead to anaemia.

It’s important to report any changes in your menstrual cycle to your doctor. Menstrual problems can affect your physical and psychological well-being but they are usually readily diagnosed and treatable.

Menstruation and pregnancy It may be difficult for you to become pregnant if you are having irregular periods. It will be harder to monitor your menstrual cycle and to predict when ovulation (egg release) will occur. If you are trying to get pregnant, talk to your doctor about how you might manage irregular periods and your aim to get pregnant.

Vaginal thrush is common in all women but occurs more frequently and with greater severity among HIV-positive women. Symptoms include an itchy crotch, stinging when urinating, a dry or sore vagina during sex and a thick white (usually odourless) discharge. Thrush can also occur in other parts of the body (the mouth and the oesophagus), although that is more common when the immune system is weaker.

Thrush is caused by a naturally occurring yeast (candida) which usually lives in harmony with its human host in the gut, the folds of the skin, the mouth, the vagina and the anus. Thrush occurs when the balance of this yeast is disturbed and the candida multiplies out of control. If the immune system is not working well, candida can start to behave like an infection. Thrush is less common when women are on HIV treatment and the immune system becomes stronger.

How is it treated?

A range of topical antifungal agents is available. Broad-spectrum anti-fungal creams or tablets (such as Canesten) are available from the chemist. You won’t need a prescription. Some people suggest live yoghurt containing lactobacillus acidophilus works although many health practitioners maintain the bacteria in commercial acidophilus yoghurt is ineffective.

For more serious thrush, antifungal drugs may be used. Fluconazole is often used to treat severe or recurring thrush but it (and other medications) can cause liver problems in people who have hepatitis C, although this is rare. If you have hepatitis C, it is extremely important to discuss treatment options thoroughly with your GP, and if possible, find an alternative treatment.

To help prevent vaginal thrush:

• Wipe your bottom from front to back after going to the toilet.
• Avoid using soap to wash the genital area.
• Avoid using antiseptics, douches or perfumed sprays in the genital area.
• Avoid using perfumed toilet papers and menstrual products.
• Avoid wearing tight-fitting pants and synthetic underwear.
• Consider changing your clothes-washing detergent and don’t use fabric softeners.

Note: Thrush is not considered a sexually transmissible infection, however, women can be re-infected by male partners during unprotected sex because thrush can be found under a man’s foreskin. This is not common but if you think this may be happening, speak to your doctor. For further information about thrush, see Melbourne’s Sexual Health Centre’s factsheet.

The human papillomavirus (HPV) is a very common sexually transmissible infection. Most people will have it at some point in their life. It’s possible for your body to clear HPV infection by itself but women with HIV are much less likely than HIV-negative women to clear the infection.

Some strains of HPV can cause abnormal cervical cells to develop. If not treated, they can lead to cervical cancer, particularly in women who also smoke. Women living with HIV, especially those aged over 40, have a higher chance of developing abnormal cervical cells caused by HPV than women without HIV. Treatment for abnormal cervical cells is highly effective provided they are detected early.

HPV can also cause anal cancer. The association between HIV and anal cancer is an emerging area of knowledge. If you have any concerns, talk to your doctor.

A vaccine against HPV is available. It is free to young men and women, however, it is only effective if given before a person is infected. Given most adults are infected with HPV, it is unclear whether the vaccine would be effective for most adult women with HIV. Speak to your doctor. Melbourne’s Sexual Health Centre provides more information in their factsheet about HPV.

Pelvic inflammatory disease (PID) is an inflammation of the pelvic area usually caused by untreated sexually transmissible infections like gonorrhoea or chlamydia. Some women have PID without knowing or without noticing any symptoms. Untreated PID becomes increasingly painful and can cause infertility. PID seems to be more common and more severe among HIV-positive women. The symptoms can be mild, moderate or severe:

• pain or cramps in the lower back and abdomen
• pain during intercourse
• deep pelvic pain
• pain going down to the top of the legs
• bleeding between periods
• vaginal discharge that is smelly and itchy
• high temperature
• fatigue

If you notice any of these symptoms or have any concerns about PID, talk with your doctor. PID must be treated by antibiotics. In severe cases women may need to be admitted to hospital.

The main message about cervical cancer for HIV-positive women is that early detection is critical. Cervical cancer is a preventable condition, and if diagnosed at an early stage, it can be cured.

Regular Pap smear tests are a very effective way to identify or prevent cervical cancer because cervical cancer usually develops slowly. Before cancer appears, the cells of the cervix go through changes known as dysplasia. Not all dysplasia mean you have cancer or are likely to get it, but sometimes it does.

The National Cervical Screening Program recommends all women aged between 18 and 70 who have ever been sexually active have regular Pap tests. Women with HIV should have Pap tests every six or twelve months because the kinds of cervical cell abnormalities that can lead to cancer are more common in HIV positive women. Research also suggests that some treatments may be less effective in women with HIV. Early detection is key!

Checkout the Positive Life NSW factsheet: HIV & your Cervix — Looking after your cervical health

Osteoporosis describes weakening of the bones through loss of bone density. It is very common — more than a million Australians have it. Osteoporosis is more common in women who have gone through menopause than younger women because of the lowering of female hormone levels (oestrogen) in the body which occurs during menopause.

People with HIV tend to have lower-than-normal bone density. It’s not entirely clear why this is, but it seems likely it is caused both by HIV and some HIV treatments. Women with HIV and hepatitis B or C co-infection may have an increased risk of reduced bone density. Bone density can be painlessly measured with a special scan. If you are aged over 50 and haven’t had a bone density scan, or if you are worried about your bone density, you could ask to have one done.

There are a number of things you can do to reduce loss of bone density and its effects. These include doing regular weight-bearing exercise (such as walking, running, or climbing stairs) and having a healthy diet, with plenty of calcium and vitamin D. Oily fish, liver, fortified spreads and cereals, and egg yolks are a good source of vitamin D, as is sunlight. Calcium can be found in milk and other dairy products, leafy green vegetables such as kale and broccoli, beans such as soy and baked beans, nuts, sesame seeds and many types of fish, such as salmon and sardines.

Some women with HIV may be advised to take vitamin D supplements. Some may also be advised to take calcium supplement tablets, particularly if your diet does not include many of the foods containing this nutrient. Taking too much of a supplement can be harmful so it is a good idea to talk to your GP or someone at your HIV clinic before you start. There is no clear evidence that vitamin D supplements help reduce the risk of bone loss in people with HIV but it does help your bones absorb calcium.

Remember — smoking and heavy drinking can increase your risk of osteoporosis. For more general information about osteoporosis, visit the Osteoporosis Australia website. For information about HIV and bone health, see Your Body Blueprint.