by Shari Margolese
July 2003 (reviewed and revised July 2006 by Terri Creagh)
Certain gynecological (GYN) conditions are more common, more serious and/or more difficult to treat in HIV+ women than HIV- women. If left untreated, some GYN infections can develop into more serious conditions such as pelvic inflammatory disease (PID) or cervical cancer.
There are many forms of herpes. The most common forms of herpes are herpes simplex virus-1 and herpes simplex virus-2. Although herpes-1 is most often associated with cold sores, both forms may be sexually transmitted and can cause genital herpes.
Like other viruses, herpes remains in your body for life. It hibernates in nerve roots when it's not causing symptoms such as painful blisters or open sores in the genital area. Herpes outbreaks can happen over and over again and may be linked to stress, fatigue, lack of sleep, menstruation, or genital friction.
HIV+ women tend to have more frequent and more difficult-to-treat herpes breakouts than HIV-negative women. Studies have found that, in HIV+ people who also have herpes, just treating HIV does not necessarily lessen the number or severity of herpes outbreaks. Herpes can be treated using antiviral drugs such as acyclovir (Zovirax™), valacyclovir (Valtrex™), and famciclovir (Famvir™).
Human Papillomaviruses (HPVs) are the most common sexually-transmitted infection in the United States. The Centers for Disease Control and Prevention estimates that about 6.2 million Americans become infected with genital HPV every year. Studies suggest that over 50% of all sexually active men and women become infected with HPV at some time in their lives.
One study found HPVs in 77 percent of HIV+ women. Different types of HPV cause warts or abnormal cell growth (dysplasia) near the anus or cervix. More than 95% of cervical cancers have been shown to be associated with HPV types 16, 18, 31, 33, and 45. HPV may also cause cancer in the vagina, vulva, and anus.
In June, 2006, the Food and Drug Association (FDA) approved a vaccine called Gardasil™ for prevention of cervical cancer. The vaccine is approved for girls and women who are 9 - 26 years of age. Gardasil™ is effective in preventing cervical cancer caused by HPV types 16 and 18, which cause approximately 70% of all cervical cancers and in preventing infection with HPV types 6 and 11, which cause approximately 90% of all genital warts. Gardasil™ is a recombinant vaccine (contains no live virus) that is given as 3 injections over a 6-month period.
However, women who are already infected with HPV are not protected by the vaccine. Also, Gardasil™ does not protect against less common HPV types not included in the vaccine. Therefore, doctors still recommend regular Pap smears to detect changes in the cervix (dysplasia) before they become cancerous, so that women can receive treatment before cervical cancer develops. When dysplasia is detected and treated early, cervical cancer can be prevented.
Anal HPV is also very common among HIV+ women. An anal Pap smear and physical examination are the best ways to detect anal dysplasia. It is important to ask your doctor to perform these tests on a regular basis.
Several treatments are available for HPV, but they generally do not cure the disease, and some have significant side effects. These treatments also tend to be expensive, so it is important that people who have HPV discuss the pros and cons of treatment with a doctor who is experienced in treating HPV in HIV+ patients.
Candidiasis is a very common vaginal infection caused by yeast (fungus). Symptoms include itching, burning, and pain around your vagina, labia, or anal area. You may also have a thick, cottage cheese-like vaginal discharge. HIV+ women often have recurring yeast infections that are difficult to treat. You are more likely to experience yeast-related problems if you:
- Have low CD4 cell counts
- Take antibiotics, steroids, or birth control pills
- Douche, wear tight underwear, or use scented soaps
- Use over-the-counter drugs frequently to treat yeast infections or don’t finish the full course of treatment
- Over-the-counter creams like Monistat or Gyne-Lotrimin or prescription anti-fungal creams (HIV+ women often need longer courses of treatment)
- Prescription oral antifungal drugs such as Nizoral (ketoconazole), Diflucan (fluconazole), or Sporanox (itraconazole) for difficult-to-treat infections. Many antifungal drugs interact with HIV drugs. Some of them are also not recommended for pregnant women. Make sure your doctor knows what HIV drugs you are taking and whether you are pregnant or are trying to become pregnant.
Prevention of yeast infections. If you think you may be prone to vaginal fungal infections, there are some things you can do to help prevent them. First, you can drink milk that contains acidophilus or eat yogurt with active cultures. There are also over-the-counter acidophilus supplements you can take, but you should make sure you take one that has a high level of active cultures. Also, some foods or food ingredients can promote the growth of yeast. Nutritionists recommend that you avoid foods containing yeast, sugar, dairy foods, wheat, and caffeine. If you smoke or drink alcohol, you should be aware that alcohol and nicotine can also promote the growth of yeast.
Syphilis is a sexually transmitted infection caused by bacteria. The first symptoms of syphilis usually occur about three weeks after exposure. The first symptom is a hard, painless, red sore at the site of sexual contact. This sore usually disappears after 2-6 weeks. Within one week to six months after the sore heals, symptoms of secondary syphilis may occur. These symptoms include swollen lymph glands, a rash especially noticeable on the palms of the hands and soles of the feet, and painless sores on various parts of the body.
Having syphilis can make you more likely to transmit HIV if you are already HIV+, and you are more likely to contract HIV from a partner who has both HIV and syphilis. Penicillin is the standard treatment for syphilis, but doxcycline or tetracycline can be given to patients who are allergic to penicillin.
Other sexually transmitted infections commonly seen in HIV-positive women include chlamydia, gonorrhea, bacterial vaginosis, and trichomonas. Antibiotics are available to treat these conditions. Your doctor can diagnose these infections and prescribe effective treatment. It is important to treat these conditions, because having these infections may make it more likely that you will transmit HIV, if you are HIV+ already. In addition, chlamydia and gonnorhea can cause pelvic inflammatory disease.
Pelvic Inflammatory Disease (PID)
PID refers to inflammation in the upper genital tract. (The genital tract includes your vagina, cervix, ovaries, uterus, and fallopian tubes.) PID is often caused by a number of common infections, including the sexually transmitted diseases (STDs) gonorrhea and chlamydia. PID starts after these infections travel up from the vagina to other organs in the body, where they can cause serious damage.
The most common symptoms of PID are lower abdominal pain, irregular menstrual cycles, non-menstrual bleeding, vaginal discharge, and painful or frequent urinating. HIV+ women who develop PID should be carefully followed by their doctors as they may need to be hospitalized and treated with antibiotics.
Although there is little conclusive research regarding HIV+ women and menstruation, many HIV+ women report menstrual irregularities or worse premenstrual syndrome (PMS). Some women have excessive bleeding while others stop menstruating altogether (amenorrhea). If you have any of these symptoms, seek medical attention to determine the cause.
It is important to check into all possible causes of amenorrhea. These may include anemia, pregnancy, ovarian cysts, opportunistic infections, menopause or other GYN conditions. Other factors may include using some side effects of HIV drugs and other meds (like megestrol), street drugs (especially heroin and marijuana), and poor nutrition. Finally, body weight changes, stress and too much exercise can interrupt the menstrual hormone necessary for normal periods to occur.
Anemia is very common among HIV+ women and may be related to abnormal menstrual cycles. Since anemia has been shown to be a risk factor for progression of HIV disease, it is important to talk to your doctor about whether you are anemic and what treatments or preventive measures you can take.
If you have menstrual problems your doctor may prescribe birth control pills to help regulate your cycles. Birth control pills interact with many HIV drugs. Some interactions can cause the birth control pill to stop working and increase your risk for pregnancy. Others can cause decreased levels of HIV drugs and put you at risk for rising levels of HIV in your body and drug resistance. It is important to discuss drug interactions with your doctor before taking birth control pills or any other hormones.
Menopause usually occurs in women at 38 – 58 years of age because of natural changes occurring in the body, including the declining production of estrogen. Symptoms of menopause include heavier or abnormal periods, hot flashes, and vaginal dryness.
Some studies have suggested that women with HIV may experience menopause earlier than HIV-negative women. This may be due to one or more of many factors including anemia, decreased hormone production, illness, weight loss, effects of HIV drugs, effects of street drugs, or smoking.
Many women undergo hormone replacement therapy (HRT) in order to replace the estrogen lost during menopause. As with any therapy, HRT has its risks and benefits. It is very important for you to discuss with your doctor all the potential risks and benefits of HRT before you consider this therapy.
HIV+ women are 10 times more likely to have abnormal Pap smears than HIV-negative women. An abnormal Pap smear can indicate inflammation, infection, dysplasia, or cancer. These abnormal Paps are usually associated with low CD4 cell counts and HPV. It is very important for HIV+ women to have regular Pap smears. The Centers for Disease Control (CDC) recommend the following:
- HIV+ women should have a complete gynecological examination, including a Pap smear, when they are first diagnosed and when they first seek care during pregnancy.
- HIV+ women should have another Pap six months later.
- If both tests are negative, yearly screening is recommended.
- Women who have symptomatic HIV infection or who have had dysplasia in the past should receive a Pap smear every 6 months.
Finding Good Care
Regular GYN exams and Pap smears are crucial to your health since many GYN conditions do not have obvious symptoms and can get worse without your realizing it. Detection and treatment in the early stages can prevent a GYN condition from progressing.
Tell your doctor about any problems you are experiencing and have regular GYN exams to look for problems that you might not know exist. If your doctor isn't skilled at screening and diagnosing GYN conditions, or you would rather see a specialist, ask for a referral to a gynecologist who is experienced in treating women with HIV. Be sure that your HIV doctor is aware of results from GYN screening tests and any treatments you might be on for GYN conditions. Make sure that your gynecologist is aware of what medications you are taking for other conditions.
Aaron E, Levine AB. Gynecologic care and family planning for HIV-infected women. (Aug, 2005) AIDS Reader 15(8):420-423,426-428.
Ameli N, Bacchetti P, Morrow RA, Hessol NA, Wilkin T, Young M, Cohen M, Minkoff H, Gange SJ, and Greenblatt RM. (2006) Herpes simplex virus infection in women in the WIHS: Epidemiology and effect of antiretroviral therapy on clinical manifestations. AIDS 20(7):1051-1058.
October 2005. Gynecological conditions and HIV/AIDS. The Body. Retrieved from http://www.thebody.com/pinf/gyn_conditions.html on July 21, 2006.
Levine AM, Berhane K, Roksana K, Cohen M, Masri-Lavine L, Young M, Anastos K, Augenbraun M, Watts, H. (2004) Impact of highly active antiretroviral therapy on anemia and relationship between anemia and survival in a large cohort of HIV-infected women: Women's Interagency HIV Study. Journal of Acquired Immune Deficiency Syndromes 37(2):1245-1252.