TREATMENT ISSUES: Special Edition - Volume 6, Number 7, Summer/Fall 1992; The Gay Men's Health Crisis Newsletter of Experimental AIDS Therapies
Patricia Kelly, FNP

Studies from the Bronx, Brooklyn, and Scotland have found that HIV does not affect women's decisions to abort or to continue a pregnancy. The first report, by Selwyn et al. in 1989, found that 50% of 28 HIV-positive women and 44% of 36 HIV-negative women who learned their serostatus prior to 24 weeks gestation chose to abort their pregnancies.[1] Other factors, such as whether or not the pregnancy was planned, seem to play a greater role than serostatus in determining a woman's decision. Johnstone reported similar findings among women studied in Edinburgh, Scotland who found out they were HIV-positive when they registered for prenatal care. Their reproductive decisions were not significantly different from the HIV-negative registrants despite more aggressive "directive" counseling than is customary in the United States.[2] The former two studies focused on drug-using populations while the studies by Sunderland in Brooklyn included a wider range of populations affected by HIV. In the Brooklyn study, it was noted that a small group of women who progressed to AIDS did not have subsequent pregnancies,[3] although there were no significant differences in the rate of subsequent births during follow-up. The overall fertility rate among HIV-positive women followed in central Brooklyn is similar to that in the community in general.

Bias against HIV-positive women in abortion clinics in New York City has been documented as clearly affecting women's reproductive decisions. Legislative initiatives, such as laws that prohibit use of federal dollars to fund Medicaid abortions (Hyde Amendment) laws that prohibit counselling about abortion, and the possible Supreme Court overruling of the decision that made abortion legal in this country (Roe vs. Wade)--have a substantial impact on fertility rates.

MENSTRUAL IRREGULARITIES

Irregularities in menstrual bleeding can be caused by a number of factors in HIV-positive women. These have been observed by some health care providers in New York City and include: pregnancy and menopause, HIV itself, anti-HIV drugs like AZT and ddI, drugs for opportunistic infections (OIs), cancer therapies, street drugs like heroin and crack, and methadone maintenance treatment. Since more than one of these factors may be present in an HIV-positive woman who is experiencing menstrual irregularities, identifying and treating underlying causes can be difficult. Written materials on this subject are limited. Additionally, menstruation can be affected by many different factors. Any chronic illness, for example, can affect menstrual function. As weight and body fat decrease, male hormones (androgens) do not convert as rapidly to female hormones (estrogens) and may result in a decrease in menstrual blood. A clearly-recalled history of menstrual irregularities predating HIV infection is often not available.

Data on the menstrual experience of HIV-infected women are limited. New data from an unpublished pilot survey of 46 women attending a clinic in Brooklyn found that most women experienced a variety of menstrual disorders during the year in which they were observed. Although no group of uninfected women was surveyed for comparison, it is worth noting that complaints were more frequent among women taking AZT. In fact, 89% of the 46 women in the survey who had menstrual problems were taking AZT. Comparatively, only 34% of women not taking AZT complained of menstrual problems. Additionally, of those women with menstrual irregularities, 66% had T4 counts under 500, compared to 28% of complaints from women with T4 counts above 500. There was a significant overlap between the group taking AZT and the group with more marked immune system suppression. Reported problems ran the gamut of possible disorders from irregular, excessive, or painful bleeding to scanty or infrequent bleeding.

--------------------------------------------------- An unpublished pilot survey of 46 women attending a clinic in Brooklyn found that most women with HIV experience a variety of menstrual disorders. ---------------------------------------------------

A study at Columbia University comparing 17 HIV-positive and 20 HIV-negative women with a history of intravenous drug use yielded some interesting results.[4] Absence or abnormal stoppages of menstrual periods occurred in 24% of HIV-positive women, as compared to only 13% in HIV-negative women. Likewise, bleeding between periods occurred more frequently in the HIV-positive group (18%), than in the HIV-negative group (6%).

MANAGING MENSTRUAL PROBLEMS

Heavy menstrual bleeding can compound the irregularities in blood that occur in HIV disease or as a side effect of AZT (i.e. anemia and neutropenia). Detecting the cause and treating menstrual irregularities in HIV-positive women is similar to that for HIV-negative women. An initial session between a woman and her health care provider should include the following: a complete menstrual history; history of all street and prescribed drugs taken; a blood sample for a complete blood count, including T4 counts; a pelvic examination with a Pap smear; screening to rule out chlamydia and gonorrhea infections, as well as pelvic masses; and a nutritional evaluation. In women over 35 with abnormal bleeding, sampling of cells from the lining of the uterus (the endometrium) should be obtained to rule out abnormally- growing cells which may cause cancer (neoplasia).

If a woman has menstrual bleeding despite an absence of ovulation (anovulatory bleeding), a short course of progesterone, a synthetic female hormone, can be administered. To restimulate long-term, regular periods, the use of oral contraceptives (the pill) is helpful. However, it is important to note the considerations for using the pill, outlined in the previous article. Difficult or painful menstrual periods can initially be treated with a series of exercises for the pelvis, abdomen, and back.

Additionally, over-the-counter medication such as ibuprofen (brand name, Advil) can be helpful. More severe pain can be countered with Motrin (prescription strength ibuprofen) or Syntex's expensive Anaprox (naproxen sodium).

BIRTH CONTROL METHODS

Condoms, used with a water-based lubricant, are the only known method that can protect a woman against pregnancy, STDs, and HIV infection. There is a 2% failure rate with condoms in protecting against unwanted pregnancy, so proper use is important. There is concern that women who use other methods of birth control are less likely to use condoms along with the chosen method. These women may put themselves at higher risk for STD and HIV exposure.[5] Therefore, it is important to supplement all of the following contraceptive methods with condom use by male sexual partners. It has been noted that women who use any of the following birth control methods consistently, as opposed to occasionally, may actually be better protected from HIV and STDs.[6] However, many people still assert that condom use is the best method for preventing HIV transmission.

ORAL CONTRACEPTIVES

Oral contraceptives (the pill) are tablets containing manufactured hormones similar to the ones made by a women's ovaries. Two types of birth control pills are presently available in the United States: the combination pill, which contains both synthetic progesterone (progestin) and synthetic estrogen, and the mini-pill, or progestin-only pill, which does not contain estrogen. The pill works by preventing the ovary from maturing an egg and releasing it at ovulation. It does not work to prevent the transmission of STDs. It should be stressed that the pill does not prevent HIV-infection, and condoms need to be used to prevent HIV transmission.

------------------------------------------------- In one study a prenatal care center, reproductive decisions about whether to continue or to abort a pregnancy were not significantly different regard- less of a woman's HIV status. -------------------------------------------------

To date, published research about the interaction of HIV infection and the pill has been limited to one study. Plummer and others studied a population of HIV-negative women who worked as prostitutes in Africa, and found that women using the pill were more likely to become HIV-positive.[7] This conversion was attributed to a condition called cervical ectopy, and was more common in women using oral contraceptives and in younger women (adolescents). In cervical ectopy, a group of cell that are highly susceptible to HIV-infection and that normally line the inside of the cervical canal are pushed to the outside of the cervical canal, where they more easily come in contact wit] HIV-infected semen. Cervical ectopy can also lead to easier infection of the human papilloma virus (HPV), which cause genital warts and lead to cervical cancer. There are no published data on the safety or harmfulness of oral contraceptives in women with HIV infection. It is difficult to assess the pros and cons of taking the pill for women with HIV because animal and test tube evidence exists for both the immune-suppressing and immune-enhancing effect of estrogen.[8] For more information see the previous article. However, there is not enough information to rule out the use of this method. Contraceptives with progestin-only (Micronor, Nor-QD) may be a useful alternative.

NORPLANT

Norplant is a relatively new method of contraception. Six matchstick-size rods containing progestin, the female hormone, are surgically inserted under the skin of the upper or lower arm of a woman. This device has been hailed as revolutionary because, once implanted, it provides contraception for up to five years. Although Norplant has already been used by more than half a million women around the world since it was first introduced in 1968, there are no data available concerning the effects of long-term use of Norplant. It is a reversible method of birth control, in that once the device is removed by a health care provider fertility is said to be restored immediately.

The side effects may be considerable in light of the menstrual problems commonly affecting HIV-positive women. They include changes in menstrual bleeding, such as more frequent bleeding episodes, spotting between periods, and absence of menstruation. More data are needed in general about this method in both HIV-positive and negative women. Correct condom use by male sex partners is a must for avoiding HIV transmission while using Norplant.

INTRAUTERINE DEVICES (IUDS)

The intrauterine device, or IUD, is a small plastic device that is inserted into the uterus by a health care provider. It prevents pregnancy as long as it remains in place. The length of time an IUD should be left in the uterus is debatable, possibly as long as five years. Use of an IUD is severely limited. For instance, women with STDs, abnormal uterine bleeding, anemia, pelvic infection, multiple sex partners, and a desire to have children in the future may be advised not to use an IUD.[9]

No human studies with HIV-positive women using IUDs exist. However, most health care providers do not consider an IUD a good choice for HIV-positive women because of an increased risk of infection during insertion. Also, insertion may increase the chance of developing pelvic inflammatory disease (PID). HIV-positive women who have IUDs already in place, and who have not had problems with it, should work with their provider to decide whether or not to remove the device. Considerations involved in this decision include sexual activity, risk of PID, history of sexually transmitted diseases, and willingness to use a condom. It is important to note that IUDs do not prevent the transmission of HIV and must be supplemented with condom use by male sex partners.

DIAPHRAGMS AND CERVICAL CAPS

A diaphragm is a shallow cup of thin latex rubber with a rim of flexible metal that is also covered by rubber. Once sperm-killing cream or jelly is placed inside the dome, the diaphragm is inserted into the vagina over the cervix before intercourse and left in place for 8 hours afterward. A diaphragm should not be left in place for longer than 24 hours. It works in two ways when used correctly: 1) It fits into the top of the vagina, up around the cervix, covering the cervix so that it forms a mechanical barrier to block the sperm. 2) It holds the spermicidal cream or jelly up against the cervix, so that any sperm that do manage to get by are killed before they can reach the cervical opening. A cervical cap works in a similar way but is smaller and fits over the cervix. It stays in place by suction and can remain for several days.

Diaphragms and cervical caps used with nonoxynol-9 cream or jelly are excellent contraceptive choices for HIV-positive women. However, since they both cover only the cervix, they must be used with condoms. With these methods, the use of a condom is essential for preventing disease transmission via the vulva or vaginal walls.

CONTRACEPTIVE SPONGES

One of the newer forms of birth control is the contraceptive sponge. It is marketed under the name Today Contraceptive Sponge and is a round, white sponge with a cup like imprint in the center that is soaked with spermicide. The sponge is moistened and inserted into the top of the vagina before intercourse. It works to prevent pregnancy by blocking the sperm's passage into the cervix and uterus. It also releases spermicide to kill and absorb sperm. The sponge is not as effective as the diaphragm or cervical cap. Safety concerns when using the sponge include toxic shock syndrome (TSS). While the sponge has been called the equivalent of the condom, since it is disposable, one-size fits-all, and can be purchased over the counter, its ability to prevent HIV transmission is unknown. Therefore, condoms should be used by male sexual partners to prevent transmission when using this device.

CONTRACEPTIVE FOAM

Nonoxynol-9 foam (such as Delfen) can be inserted directly into the vagina. This product has been endorsed by many feminists as a "better than nothing" method that can be used by women whose male partners refuse to use condoms. The idea is that the sperm-killing nonoxynol-9 may be able to kill HIV and prevent transmission. However, two studies have shown an increased number of red cells in the blood and inflammation in women using the sperm-killing products.[10] Additionally, some people are allergic to nonoxynol-9, and irritations can erupt on the skin. These conditions may enhance transmission of viral diseases, STDs, and HIV. More information and research are needed concerning the use of contraceptive foams before a dependable recommendation can be made.

STERILIZATION

For women who are clear about their desire not to have further pregnancies, sterilization is a viable option. It is important that this option be neither encouraged nor denied based on anything other than a woman's own personal choosing. The decision should not be based on serostatus. Condom use is needed after sterilization to prevent HIV, STDs, and viral transmission.

CONCLUSION

In addition to the pattern of medical, racial, economic, and gender- based discrimination that burdens HIV-positive women, there is a scarcity of data on gender-specific manifestations and conditions in HIV disease. There is a great need for caring and accurate clinical rigor. As evidence of the unique and serious gynecological manifestations accumulates, clinicians and researchers must turn their attention to these problems. In the meantime, the best reproductive health care services must be provided while researchers work to create clearer guidelines.

FOOTNOTES ---------

1. Selwyn PA et al. Knowledge of HIV antibody status and decisions to continue or terminate pregnancy among intravenous drug users. JAMA 261:3567-71, 1989.

2. Personal Communication, Johnstone, F, January, 1992.

3. Sunderland A. Influence of HIV infection on reproductive decisions. OB/GYN Clinics of NA 17:585-94, 1990.

4. VIIth Int'l Conf on AIDS, Abstract # M.C. 3113, Florence, June 1991. 5 VII Int'l Conf on AIDS, Abstract# Tu.D. 109, Florence, June 1990.

6. Stein Z A. HIV Prevention: The need for methods women can use. Amer J Pub Health. 460-462.

7. Plummer FA et al. Cofactors in male-female transmission of human immunodeficiency virus type 1. J Infect Dis 163:233-239, 1991.

8. Grossman C. Possible underlying mechanisms of sexual dimorphism in the immune response, fact and hypothesis. J Steroid Biochem 34:241-51.

9. Lynda Madaras and Jane Peterson Womancare (New York City: Avon, 1984) pp.124-35.

10. VI Int'l Conf on AIDS, Abstract # S.C. 36, San Francisco, June 1990; and Bird. The use of spermicide containing nonoxynol-9 in the prevention of HIV infection AIDS 5:791-6, 1991.

Copyright (c) 1992 - Gay Men's Health Crisis. Non-commercial electronic dissemination encouraged. Distributed by AEGIS, your online gateway to a world of people, knowledge, and resources. Direct Dial: v.34+: 714.248.2836; v.120/ISDN: 714.248.0433 Internet: telnet:aegis.com www: www.aegis.com

9206
GM060703

Copyright © 1992 - Treatment Issues. Reproduced with permission. Treatment Issues is published twelve times yearly by GMHC, Inc. All rights reserved. Noncommercial reproduction is encouraged. Subscription lists are kept confidential. GMHC Treatment Issues, The Tisch Building, 119 West 24th Street, New York, NY 10011  fredg@gmhc.org  http://www.gmhc.org

AEGiS is made possible through unrestricted grants from Boehringer Ingelheim, Elton John AIDS Foundation, iMetrikus, Inc., John M. Lloyd Foundation, the National Library of Medicine, and donations from users like you. Always watch for outdated information. This article first appeared in 2003. This material is designed to support, not replace, the relationship that exists between you and your doctor.

AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.

Copyright ©1980, 2003. AEGiS. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS, or the party credited as the provider of the content. .