PI Perspective #26

December 1998     View PDF     En español

Gynecological Complications in Women with HIV

While gynecological (GYN) complications are but one area of concern for women with HIV, they are critically important because they are the most commonly reported condition of women living with HIV and AIDS. When evaluating HIV-associated GYN conditions and the provision of appropriate gynecological care, it is important to consider what GYN health reveals about the status of a woman’s immune system.

What does it say about the health of a woman’s immune system, for instance, when a common GYN condition like vaginal candidiasis becomes progressively more difficult to treat? What does the absence of an HIV infected woman’s period (amenorrhea), a common menstrual abnormality in women with HIV, tell us about immune function? How does the marked increase in the rate and severity of cervical abnormalities experienced by women with HIV correspond to a weakening immune system? These are some of the questions that must help guide women and health care providers in the evaluation and treatment of GYN complications in women with HIV. These complications should also be considered in light of CD4+ cell count, an important marker of immune function. A chart of common GYN conditions and a flow chart of screening guidelines are presented later in this article.

Common GYN Complications
Vaginal candidiasis (vaginal yeast infections) is a fungal infection common in many women. It is the most common initial manifestation of HIV in women, and its prevalence increases as CD4+ cell counts decline. As immune suppression worsens, the primary location of the candida infection may shift from the vagina to the mouth (for more information on candidiasis, read Project Inform's publications, Oral Candidiasis, Vaginal Candidiasis or Systemic Candidiasis). Recurring vaginal candidiasis is often associated with more rapid HIV disease progression.

Fortunately, there are several effective forms of treatment for vaginal candidiasis, including topical creams and suppositories such as clotrimazole (GyneLotrimin) which are available over-the-counter and by prescription. If the candidiasis is unresponsive to such treatment, the antifungal drug fluconazole (Diflucan) may be necessary. For women not responding to fluconazole, the antifungal ketoconazole (Nizoral) may be an effective alternative. Dietary modifications such as decreasing sugar intake or adding lactobacillus containing yogurt or acidophilus capsules may help prevent recurrences of candidiasis. Refraining from using bleach and fabric softeners when doing laundry might also be useful.

Several studies show that the sexually transmitted disease, herpes simplex virus (HSV) type II, may take an altered course in HIV-infected people. For instance, the painful sores in and around the genitals and/or anus caused by herpes tend to be more frequent, persistent and requiring of higher doses of treatment in people with HIV. HSV ulcers persisting for over 1 month are associated with severe immunosuppression and are considered an AIDS-defining illness. Acyclovir (Zovirax), an oral pill, is most commonly used to treat genital herpes. For women with frequent HSV outbreaks, acyclovir may be helpful in preventing future outbreaks.

Pelvic inflammatory disease (PID) represents a range of inflammatory disorders of the upper genital tract, including fallopian tubes, uterus, ovaries and, in advanced stages, abdominal lining. Common symptoms of such inflammation involve chronic, moderate-to-severe pain, tenderness in the abdomen, irregular menstrual cycles, non-menstrual bleeding and painful and frequent urination. Like other gynecological conditions, PID appears to be more prevalent, severe and resistant to treatment among women with HIV, and especially women with AIDS. Indeed, the Centers for Disease Control and Prevention recommends hospitalization and intravenous antibiotics for treating PID in women with HIV. Studies indicate that relapse of PID occurs more often in women with impaired immunity.

Human papillomavirus (HPV), a sexually transmitted disease which primarily affects the cervix, plays a primary role in the development of cervical dysplasia (abnormal cells) and cancer of the cervix in women. Recent studies have demonstrated that women with HIV, particularly those with low CD4+ cell counts, have an increased frequency and severity of HPV-related cervical dysplasia. The outcome for HIV-positive women with cervical cancer, the most severe form of cervical dysplasia and an AIDS-defining illness, is much worse than for women without HIV. However, if detected early, less severe grades of dysplasia (CIN I or II) are fairly easily treated, stressing the need for regular and timely screening.

If symptoms occur, they often include multiple small warts on the vagina or around the anus. Multiple types of therapy are available. However, recent studies caution against the use of one common treatment option called cryotherapy, which involves freezing the wart. Cryotherapy can cause normal tissue to heal over deeper areas of dysplasia, causing future genital screenings to appear normal while abnormal tissue grows undetected underneath. Anecdotal reports also indicate that the aftermath of cryotherapy can be extremely painful.

Screening
Given that women with HIV have higher rates and generally more severe cases of GYN complications, it is important to screen frequently and regularly. Screening is normally done with one of two diagnostic tools, the Pap smear and/or colposcopy.

The ability of Pap smears to adequately screen for cervical cancer in women with HIV is currently under debate. Studies have shown that 15–30% of Pap smears that are considered normal are, upon subsequent colposcopy and biopsy, found to be “false-negative.” In other words, abnormal pre-cancerous cell growth passed undetected during the Pap test. The problem of false-negative Pap smears has lead some health care providers to suggest colposcopy plus biopsy as a more accurate screening procedure, particularly among HIV-positive women where early detection is most critical.

Still, colposcopy has drawbacks of its own. Not only does it require management by a specialist, colposcopy is often accompanied by a biopsy and can be a painful experience with some risk of infection and bleeding. At this point, it is difficult to say whether or not colposcopy screening is a necessary routine screening procedure for HIV-positive women without signs of an abnormal Pap smear. A promising new screening tool called Pap Plus Speculoscopy (PPS) has recently gained FDA approval. It is almost as sensitive as a colposcopy plus biopsy, is less invasive and painful and does not require a specialist.

Conclusion
Many of the GYN complications HIV-positive women experience also affect women who are not living with HIV. The same conditions tend to occur more frequently, are more serious and more difficult to treat in women with a compromised immune system. At the same time, GYN complications further compromise the immune system. Consequently, it is very important that GYN complications be diagnosed, monitored and treated under the guidance of a health care provider.

For more complete information, read Project Inform’s Gynecological Conditions in Women with HIV.

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Common GYN Conditions