Menstrual health and HIV
- women living with long-term HIV may be more likely to miss periods, but this is not a symptom of recent HIV infection.
- Menstrual blood touching intact skin is not at risk of HIV transmission.
- Some hormonal contraceptives can be used to suppress periods, but women living with HIV need to consider their treatment when choosing a contraceptive.
Can HIV affect the menstrual cycle?
Many women experience irregularities in their menstrual cycles at various times. This includes irregular periods, changes in menstrual flow and worsening of premenstrual symptoms and can sometimes indicate an underlying health problem. Most menstrual changes reported by women living with HIV do not appear to be directly linked to the virus.
However, there is evidence to suggest that women living with HIV are more likely to experience missed periods (amenorrhea). An comprehensive analysis of international research conducted in the 1990s and early 2000s on nearly 9000 women found that women living with HIV were 70% more likely to suffer amenorrhea for more than three months.
A clinical study of 828 women from 1994 to 2002 also found that women living with HIV were more likely to have unexplained amenorrhea for more than a year compared to women who were not living with HIV. For more than a third of women living with HIV, this amenorrhea was reversible.
The exact reasons for this continue to be debated. It is not yet clear whether amenorrhea is a complication of HIV infection itself or due to other risk factors that were more common among women with HIV at the time the data were collected, such as low body weight, immune suppression or a combination of factors. Additional research among women on more modern antiretrovirals (ARVs) can help answer these questions.
Amenorrhea can be associated with infertility, increased cardiovascular risk and bone health problems. Women living with HIV should always consult their doctor if they experience unexpected menstrual changes. There may be nothing wrong, but it is a good idea to check out to see what the cause may be. More detailed information is available on the NHS website.
Is a missed period a symptom of HIV?
A single missed period is not a sign of HIV. The symptoms of recent HIV infection are the same in men and women, the most common being fever, swollen glands, muscle pain and tiredness. A more detailed list of symptoms associated with HIV seroconversion can be found on another page.
There are many reasons why a woman may miss her usual monthly period, including pregnancy, stress, sudden weight loss, overweight or obesity, and extreme exercise. Any effect that HIV has on menstruation is probably related to long-term chronic infections.
Can HIV be transmitted through contact with menstrual blood?
Menstrual blood touching intact skin is not at risk of HIV transmission. If it comes into contact with broken skin or is swallowed, transmission of HIV is possible, but still unlikely. Due to the effectiveness of HIV treatment, the menstrual blood of someone living with HIV adhering to antiretroviral medication may well not have a detectable virus. (Undetectable = Not Communicable). The small number of case reports documenting HIV transmission through exposure to blood involved a significant amount of blood from the HIV-positive person, as well as open sores on the other person's skin.
Does menstruation increase the risk of HIV transmission to sexual partners in other ways?
If a person living with HIV is not on antiretroviral treatment, it is likely that the levels of HIV in their vaginal fluid will be higher during menstruation. Several studies have shown that the viral load in the female genital tract can vary during the menstrual cycle, including a 2004 study who found that viral load levels in cervico-vaginal fluid tended to peak at the time of menstruation and to reach the lowest level immediately before ovulation, usually in the middle of the cycle. This would increase the risk of HIV transmission if preventive methods (such as condoms or pre-exposure prophylaxis - PrEP) were not being used.
However, due to the effectiveness of HIV treatment, it is likely that the body fluids of someone living with HIV do not have a detectable virus. (Undetectable = Not Communicable). HIV levels in the blood and cervico-vaginal fluid are generally correlated, although the viral load in vaginal secretions may drop more slowly than in the blood, so it may not be detectable for a few months after the viral load becomes undetectable in the blood. .
If unsure, condoms, dental dams and PrEP are all options that reduce the risk of HIV infection during sex with a person living with menstruating HIV.
Are women at increased risk of HIV during menstruation?
Menstrual bleeding during a period does not in itself increase the risk of acquiring HIV. However, hormonal changes during menstrual cycles are believed to put women at greater risk than at other times. The biology of the vagina and cervix means that women, especially teenagers and older women, are generally more vulnerable to HIV and sexually transmitted infections (STDs) of the than men.
A 2015 study in monkeys concluded that immune protection is at its lowest level in the middle of the cycle, providing a "window of opportunity" for infections to enter. In addition, researchers who followed a group of 37 HIV-negative sex workers in Nairobi, in Kenya, found an association between the first stage of the menstrual cycle and factors that may mean increased susceptibility to HIV infection. The authors concluded that a better understanding of the natural hormonal cycle in the vaginal immune environment is needed to identify exactly how it influences the sexual transmission of HIV in women.
Since more research is needed to establish clarity about when women are most at risk, women should always consider using barrier methods, such as male and female condoms, to provide the best protection against STIs, including HIV, regardless of stage of your menstrual cycle.
Can women living with HIV use hormonal contraception to suppress menstruation?
Women living with HIV can use hormonal contraception to regulate or suppress their periods, whether or not they are trying to prevent pregnancy. However, it is important to take HIV treatment into account when choosing these options, as there are possible interactions between anti-HIV drugs and hormonal contraceptives, the which means that contraception may not work.
The methods that can suppress periods are:
- contraceptive injections - their reliability is not normally affected by ARVs.
- intrauterine devices / systems (IUD / S) - their reliability is not normally affected by ARVs.
- progestogen-only (POP) pills - some anti-HIV drugs may reduce their effectiveness.
- contraceptive implants - some anti-HIV drugs can reduce their effectiveness.
ARVs with the potential to affect the effectiveness of hormonal contraceptives include some protease inhibitors, NNRTIs efavirenz and nevirapine and cobicistat-boosted elvitegravir.
The interaction can occur because the anti-HIV drug and the contraceptive are processed in the liver by the same enzymes, so the contraceptive is processed more quickly than usual. As a result, contraceptive hormone levels may be too low to avoid pregnancy at all times. Anti-HIV drugs will continue to be effective and work well.
When selecting contraceptive methods, women living with HIV should always talk to a doctor or pharmacist to ensure compatibility with their antiretroviral therapy regimen. This is also important for emergency contraception (the “morning after pill”).
Does contraception increase women's HIV risk?
Observational research studies in the past have suggested a possible increased risk of HIV for women using progestin-only injectable contraceptives, such as the intramuscular injection DMPA, also known as Depo-Provera. A large recent study with a more reliable methodology, performed in four African countries, however, found no significant difference in the risk of HIV infection between women using hormonal or non-hormonal reversible contraceptive methods (implants, injections or IUDs).
King et al. HIV and amenorrhea: a meta-analysis. AIDS, 1; 33: 483-491, 2019. doi: 10.1097 / QAD.0000000000002084. You can read more about this study in our news report.
Cejtin et al. Prolonged amenorrhea and resumption of menses in women with HIV. Journal of Women's Health, 27, 2019.
Benki S et al. Cyclic shedding of HIV-1 RNA in cervical secretions during the menstrual cycle. The Journal of Infectious Diseases, 189: 2192-2201, 2004. You can read more about this study in our news report.
Scully EP. Sex differences in HIV infection. Current HIV / AIDS Reports, 15: 136-146, 2018. doi: 10.1007 / s11904-018-0383-2.
Wira CR et al. The role of sex hormones in immune protection of the female reproductive tract. Nature Reviews Immunology, 15: 217-230, 2015. doi: 10.1038 / nri3819.
Boily-Larouche G et al. Characterization of the genital mucosa immune profile to distinguish phases of the menstrual cycle: implications for HIV susceptibility. The Journal of Infectious Diseases, 219: 856-866, 2019. https://doi.org/10.1093/infdis/jiy585
Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomized, multicentre, open-label trial. The Lancet, online ahead of print, 2019. You can read more about this study in our news report.
Thanks to Dr Melanie Murray and Dr Nneka Nwokolo for their advice.