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Brief Summary

GUIDELINE TITLE

Medical care for menopausal and older women with HIV infection.

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Medical care for menopausal and older women with HIV infection. New York (NY): New York State Department of Health; 2008 Mar. 10 p. [22 references]

GUIDELINE STATUS

This is the current release of the guideline.

BRIEF SUMMARY CONTENT

 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Identification and Prevention of Human Immunodeficiency Virus (HIV) in Older Women

Risk Assessment and Risk-Reduction Counseling

Clinicians should discuss sexual and other risk behaviors and HIV prevention education at routine clinical visits for all HIV-infected women, regardless of age.

Key Point:
Use of water-based lubricants and treatment with vaginal estrogen preparations, which are considered safe and effective, can decrease the discomfort that some older women may experience with condom use.

Identification of Acute Retroviral Syndrome and New Diagnoses in Older Women

Clinicians should consider acute retroviral syndrome in the differential diagnosis for older women who present with flu-like illnesses.

Routine Primary Healthcare Recommendations for Older HIV-Infected Women

Table. Routine Primary Healthcare Recommendations for Older HIV-Infected Women1
Procedure Frequency
Gynecological evaluation At baseline and annually and as indicated for ongoing problems. This examination should include direct visualization of the vulva, vagina, and cervix, and a bimanual pelvic examination that includes a digital rectal examination.
Cytologic screening
  • Cervical Pap tests
    • Baseline and then 6 months after baseline; repeat annually, as long as results are normal
    • Abnormal Pap tests results should be repeated every 3 to 6 months until two successive normal Pap tests are reported2
  • Anal Pap tests
    • Baseline and annually for women with a history of anogenital condyloma or abnormal cervical/vulvar histology
Post-hysterectomy cervical screening3 Annual cervical Pap test when:
  • Hysterectomy was performed because of high-grade dysplasia, HPV-related anogenital dysplasia of the cervix, or carcinoma
  • A supracervical hysterectomy (uterus removed and cervix left in place) was performed
  • The reason for the hysterectomy cannot be determined by patient self-report or other means
  • Any cervical tissue remains
STI screening
  • RPR or VDRL for syphilis with verification of positive test by confirmatory FTA-Abs or TP-PA
    • Baseline and at least annually; every 3 months for patients with ongoing high-risk behavior
  • Gonorrhea and chlamydia4,5
    • Baseline and at least annually
Mammography Annually, starting at age 406
Bone mineral densities Baseline at menopause and after 50. The frequency thereafter has not been determined7

FTA-Abs, fluorescent treponemal antibody absorbance; HPV, human papilloma virus; RPR, rapid plasma reagin; STI, sexually transmitted infection; TP-PA, Treponema pallidum particle agglutination; VDRL, Venereal Disease Research Laboratory.

  1. 1Routine immunizations can be found in the National Guideline Clearinghouse (NGC) summary of the New York State Department of Health (NYSDoH) guideline Prevention of Secondary Disease: Immunizations; routine diagnostic screening tests can be found in the NGC summary of the NYSDoH guideline, Primary Care Approach to the HIV-Infected Patient.
  2. 2Colposcopy should be performed for women with abnormal Pap tests. Follow-up would then vary on a case-by-case basis. Women with cervical high-grade intraepithelial lesion (HSIL) should be referred for high-resolution anoscopy.
  3. 3Annual Pap tests are not recommended for HIV-infected women who have undergone a total hysterectomy for reasons not related to cervical abnormalities.
  4. 4All sites of exposure are screened. For specific recommendations regarding the types of assays used, refer to the NGC summary of the NYSDOH guideline Gonococcal and Chlamydial Infections in Management of STIs in HIV-Infected Patients.
  5. 5For women with one of the following: recent STI, multiple sexual partners, a new sexual partner, or a sexual partner with symptoms of an STI.
  6. 6American Cancer Society (ACS), available at: http://caonline.amcancersoc.org/cgi/reprint/53/3/141. However, the optimal age of initiation for breast screening and the intervals for mammography are still being studied.
  7. 7National Osteoporosis Foundation, available at: http://www.nof.org.

Use of HAART in the Older HIV-Infected Woman

Clinicians should follow standard guidelines for initiation of HAART in older women (see the NGC summary of the NYSDoH guideline Adult Antiretroviral Therapy).

Adverse Drug Reactions and Drug-Drug Interactions

Clinicians should assess for signs or symptoms of adverse reactions, drug-drug interactions, and cumulative side effects when patients are receiving multiple types or classes of medications for comorbidities and/or HIV.

Hormone Replacement Therapy (HRT) in HIV-Infected Women

Clinicians should refer HIV-infected women experiencing severe symptoms of menopause to a clinician experienced in the most current management of menopausal symptoms. An individualized risk/benefit analysis of the use of HRT should be performed regardless of whether or not the woman is receiving HAART.

Clinicians should discuss with HIV-infected women the benefits of exercise, weight control, improved nutrition, including calcium supplementation, and smoking cessation for the prevention of osteoporosis and coronary heart disease.

Guidelines for HRT

Table. Guidelines for Prescribing Hormone Replacement Therapy
  • Provide HRT for the shortest possible time at the lowest effective doses
  • Consult with the patient at least once a year about HRT therapy, working toward successfully discontinuing the use of HRT
  • Recommend regular breast cancer screening
    • Annual clinical breast examinations
    • Annual mammograms for women >40*

*The optimal age of initiation for breast screening and the intervals for mammography are still being studied.

Alternatives to HRT

Table. Alternatives to Hormone Replacement Therapy
Signs or Symptoms Alternative Treatment
Hot flashes/menopause symptom alleviation
  • Paroxetine
  • Gabapentin
  • Clonidine
Vaginal dryness/atrophy
  • Water-based lubricants and vaginal estrogen preparations
Prevention or treatment of osteoporosis
  • Alendronate sodium, risedronate, raloxifene, calcitonin
  • Smoking cessation
  • Decreased alcohol consumption
  • Increased physical activity
  • Calcium and vitamin D supplementation and correction of malnutrition

HRT Interactions with HAART

Because amprenavir and fosamprenavir levels are reduced with ethinyl estradiol and norethindrone use, they should not be used with hormone replacement therapy.

Mental Health and Substance Use

Clinicians should perform a mental health assessment at baseline and at least annually. The assessment should include the following components:

  • Cognitive impairment, depression, anxiety, posttraumatic stress disorder, suicidal/violent ideation, and alcohol and substance use
  • Sleep habits and appetite assessment
  • Psychiatric history, including psychotropic medications
  • Psychosocial assessment, including domestic violence, housing status, and presence of social support

Clinicians should refer patients to appropriate mental health and substance use treatment providers when indicated.

Clinicians should incorporate selected brief screening instruments in the patient assessment. These instruments should be tailored for optimal use at initial, annual, and interim visits. The chosen screening instruments should be adjusted for the patient's mental health or substance use history.

Key Point

Depressive symptoms and negative life events have been associated with symptoms of menopause in HIV-infected women.

Sexual Dysfunction

Clinicians should assess older HIV-infected women for sexual dysfunction and/or decreased libido; testosterone supplementation should not be used for treating these conditions.

CLINICAL ALGORITHM(S)

None provided

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EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting is not specifically stated.

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IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Medical care for menopausal and older women with HIV infection. New York (NY): New York State Department of Health; 2008 Mar. 10 p. [22 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2008 Mar

GUIDELINE DEVELOPER(S)

New York State Department of Health - State/Local Government Agency [U.S.]

SOURCE(S) OF FUNDING

New York State Department of Health

GUIDELINE COMMITTEE

Women's Health Committee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Committee Chair: Mary Jo Fink, MD, Columbia Center for Family Medicine, New York, NY

Vice-Chair: Barbara C Zeller, MD, Project Samaritan AIDS Services, Inc , Bronx, NY

Committee Members: Machelle Allen, MD, Bellevue Hospital Center , New York, NY; Kathryn Anastos, MD, Montefiore Medical Center, Bronx, NY; Jeffrey M Birnbaum, MD, MPH, SUNY Downstate Medical Center, Brooklyn, NY; Susan E Cohn, MD, MPH, University of Rochester Medical Center, Rochester, NY; Vanessa E Cullins, MD, MPH, MBA Planned Parenthood Federation of America, New York, NY; Katherine D LaGuardia, MD, MPH, FACOG, Ortho-McNeil Pharmaceutical, Inc., Raritan, NJ; Howard Minkoff, MD, Maimonides Medical Center, Brooklyn, NY; Diane M Rudnick, MEd, New York State Department of Health AIDS Institute, New York, NY; Renee Samelson, MD, MPH, Albany Medical Center, Albany, NY; Diane J Tufaro, NP, AIDS Care Center, Valhalla, NY; Janice R Verley, MD, SUNY at Stony Brook, East Meadow, NY; Mary Vogler, MD; Weill College of Medicine, New York, NY; Barbara L Warren, BSN, MPH, PNP, New York State Department of Health AIDS Institute, Albany, NY

AIDS Institute Staff Liaison: Gina M Brown, MD, New York City Department of Health and Mental Hygiene, New York, NY

Principal Contributor: Barbara Zeller, MD, Project Samaritan AIDS Services, Inc., Bronx, NY

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

Electronic copies: Available from the New York State Department of Health AIDS Institute Web site.

AVAILABILITY OF COMPANION DOCUMENTS

This guideline is available as a Personal Digital Assistant (PDA) download from the New York State Department of Health AIDS Institute Web site.

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on July 3, 2008.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is copyrighted by the guideline developer. See the New York State Department of Health AIDS Institute Web site for terms of use.

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DISCLAIMER

NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.
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