Importance of including menopause and bone health in management of HIV positive women
At least three posters at BHIVA 2019 looked at aspects of women’s health in relation to the menopause.
Importance of annual menopause review
Munatsi and colleagues from Nottingham University Hospitals presented results from a questionnaire looking at contraception, menopausal symptoms, comorbidities, medications and lifestyle risk factors in 31 HIV positive women aged 45-56. Overall, 13% (152/1200) of this clinic’s population are women of this age. 
A case note review was then used to compare to clinical management, including FRAX score and cardiovascular risk.
Most women (90%) were on ART with undetectable viral load. Ethnicity included 61% black African, 13% white British and 6% Asian.
None of the women had had a menopause review – even though 40% had menopause symptoms. Awareness of HRT was low (only 20%) with only half of women having information from a healthcare professional. The remaining 60% were still having regular periods but were likely to be reaching the menopause in the near future.
The results have been used to change practice in Nottingham by emphasising an annual review and including more information about HRT and guidance about how to deal with the menopause. The study also suggested the importance for women to be able to access specialist services.
Given that BHIVA guidelines state that all HIV positive women aged 45-56 should have an annual menopause review with the option for hormone replacement therapy (HRT), the review from Munatsi and colleagues should be an immediate prompt for other clinics to review their services.
Low age at osteoporosis – signal to review guidelines?
Yvonne Gilleece and colleagues from Brighton presented DEXA results on bone health from 40 HIV positive women seen at their specialist women’s HIV service. 
Results were available to 37/40 women and mean age was 51 years (range 36 to 84).
DEXA results were normal in 38% (14/37), osteopenia in 41% (15/37) and osteoporosis in 21% (8/37) and most of the women with osteoporosis (7/8) were post-menopausal. The median age for each category was 51 years (42–58), 48 years (36–60) and 53 years (46–84) respectively.
Although the study had small numbers, the authors highlighted the low median age for osteoporosis and that this was twice as common in HIV positive women than HIV positive men. Also that the low ages for osteoporosis in this population and the related increased risk of fragility fractures warrants a review in current BHIVA monitoring guidelines.
Current BHIVA guidelines recommend BMD risk factor assessment: at first HIV diagnosis, before ART and then every 3 years in individuals on ART who are ≥ 50 years of age. Bone mineral density assessment is advised initially using FRAX and also with DEXA scanning in all women aged ≥65 years and women >50 years old if they have an intermediate to high FRAX score and/or additional risk factors.
These guidelines may not identify all women at risk of low BMD.
Under-use of current guidelines
A third poster presented complimentary results to both these studies.
F Hirst and colleagues from Solent NHS Trust presented result from a retrospective case note review of 44 women older than 50 years to see how closely their hospital followed BHIVA guidelines for bone health. 
Only 10/44 women (23%) had a documented discussion on HRT with 3/44 (7%) receiving HRT. 2/44 (4.5%) women had a history of a low-trauma fracture and 1/44 (2.3%) reported parental hip fracture.
Only 29/44 (66%) had a documented FRAX score. The score for the remaining patients was calculated for the study and overall, based on the FRAX score, 27/44 (61%) were categorised as intermediate risk, with 21 of those (78%) included solely through inputting HIV as a secondary cause of osteoporosis in the FRAX tool. Of the 27 women at intermediate risk, 7 (27%) had been referred for a DEXA scan.
The study concluded that BHIVA guidelines were only being followed to a moderate degree, and that suboptimal menstrual questions and missing FRAX scores were underestimating bone mineral density risk in this cohort.
These studies highlight aspects of HIV positive women’s health that should prompt other doctors and clinics to review the management of this patient group.
More than 10,000 HIV positive women aged 45-56 attend UK HIV clinics.
- Munatsi S et al. The menopause experience: a quality improvement project. BHIVA 2019. Poster abstract P151.
- Gilleece Y et al. No bones about it: high rates of osteoporosis in women living with HIV. BHIVA 2019. Poster abstract P68.
- Hirst F et al. Assessment of bone health of women living with HIV aged>50 years in clinical practice: are we doing enough? BHIVA 2019. Poster abstract P52.