PI Perspective #23

November 1997     View PDF     En español

Hormone Replacement Therapy

The use of hormone replacement therapy and hormonal contraceptives is a difficult issue for women living with HIV.

Advocates have battled for studies of possible interactions between HIV therapies and oral contraceptives (OC). However, it is not oral contraceptives (birth control pills), but the use of other hormonal therapies (such as implants and injections) that needs addressed. For many women with HIV, pregnancy plays little part in deciding on therapies, which are used to manage menstrual flow, menopause and pre-menstrual syndrome (PMS), or to affect body composition. These uses, as well as the impact of HIV therapies, are not addressed in simple oral contraceptive drug interaction studies.

HIV has an impact on hormone levels; in men, testosterone is often deficient and replacement therapy can increase energy levels, manage depression and promote weight. In women, abnormal menstrual cycles, weight loss, gynecological infections, headaches and fatigue are common and may relate to decreased estrogen. Estrogen supplementation is not a simple choice, as it can increase the risk of breast and endometrial (the membrane lining the uterus) cancers.

The issue of abnormal menstrual cycles and premature menopause in HIV positive women has been debated, and studies comparing menstrual cycle differences in HIV-positive and HIV-negative women have shown conflicting results. Many doctors view abnormal menstrual cycles as an inconvenience rather than a serious medical condition and thus don’t address them aggressively. However, a recent study reported the use of hormone replacement in HIV-positive post-menopausal women predicted survival. This implies hormonal regulation may have broader health implications than previously assumed for women with HIV.

There are also questions about the relationship between hormone levels and the immune system, drug metabolism and body composition. Little is known about how hormonal therapies used by women interact with anti-HIV drugs. The few oral contraceptive studies done, have only looked at how HIV drugs and contraceptives affect the blood levels of one another. For instance, nelfinavir (Viracept) decreases the levels of ethinyl-estradiol (a birth control pill) by 50% and some doctors suggest women double their dose to prevent pregnancy. What does this mean if ethinyl-estradiol (which contains, estrogen and progestin) is used for hormone replacement therapy rather than birth control? One concern is that a woman who doubles the dose may increase her risk of cancer. But the risk of cancer may be less when hormone therapy is used to resolve existing deficiencies, as opposed to boosting otherwise normal levels to prevent pregnancy. The reverse issue also exists; anti-HIV drugs may be metabolized differently in the presence of birth control medications. What are the interactions and effects of hormonal contraceptive or replacement therapies, such as the implants or injections, when used with anti-HIV drugs?

Replacement may also impact body composition changes and wasting. For instance, Depo-provera, an injectable synthetic hormone administered every 3 months, can increase body weight about 5 pounds per year. One study found that over 5 years, women gained 25 pounds on average, indicating that the weight gain is not transient. As with Megace, this weight seems to be primarily fat, not muscle. Injected once quarterly, Depo could be a simple, dual-use alternative to therapies like Megace for weight maintenance.

Research specific to hormone levels and the effects of hormone replacement therapy on women living with HIV is overdue. The better our understanding of the impact of hormonal imbalances on the immune system, drug metabolism and general health, the more effective women with HIV and their health care providers can be in addressing these issues.

Medicaid Managed Care

LAST      NEXT