Although previous studies indicate that HIV is a risk factor for missed menstrual periods, or amenorrhea, the downstream effects of amenorrhea and its associated hormonal dysregulation in these women remain poorly understood, explains Elizabeth King, MD. For a study published in the Journal of Acquired Immune Deficiency Syndromes, Dr. King and colleagues sought to determine if women with HIV and amenorrhea suffer disproportionately from osteoporosis when compared with those with normal menstrual cycles. “We suspected this would be the case, as women with amenorrhea have altered estrogen and progesterone levels, hormones that are well established as important regulators of bone metabolism and health,” Dr. King notes. “As persons living with HIV are already at much higher risk for osteoporosis and fractures than the general population, appreciating unrecognized risk factors is crucial in optimizing their care.”

In the cross-sectional study, bone mineral density (BMD) was compared in women with HIV with that of HIV-negative control women, all aged 19-68 and with similar BMIs, ethnicity, and substance use status. Participants were stratified by amenorrhea history, defined as past or present lack of menses for a year or longer at age 45 or younger and not due to surgery, breastfeeding, pregnancy, or hormonal contraception.

Prolonged amenorrhea was experienced by 21% of women with HIV, compared with 9% of controls. “Our study confirmed that women living with HIV have significantly lower BMD than HIV-negative controls,” says Dr. King, based on the finding of significantly lower total hip and spine Z-scores in those with HIV. “Importantly, among women with HIV, we found that those who had prolonged amenorrhea had lower hip BMD than those without, and that amenorrhea is an independent risk factor for decreased hip BMD.” Women with HIV and amenorrhea also had higher rates of substance use, smoking, opioid therapy, and hepatitis C coinfection, as well as lower CD4 nadir.

Dr. King notes the need for future studies exploring the varied hormonal changes experienced by women with HIV during periods of amenorrhea. In the meantime, she encourages physicians to “routinely screen for amenorrhea in women with HIV and, if present, to consider earlier fracture risk assessment than what is currently recommended in guidelines.”