Gynecologic Issues in the HIV-Infected Woman

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In this article, gynecologic conditions of increased importance in the HIV-infected woman are discussed. Women living with HIV may have an increase in menstrual disorders, lower genital tract neoplasias, gynecologic surgery, and sexually transmitted infections. The literature relevant to choosing a method of contraception for HIV-positive women is also discussed. With the advent of HAART, seropositive women are now facing issues around longevity, such as menopause and disorders of bone mineral density, as well as those associated with fertility.

Section snippets

Menstrual disorders

HIV-infected women frequently report changes in their menstrual cycles [1], and early reports suggested an increase in abnormal menses in this population [2], [3]. HIV-infected women may have menstrual dysfunction for a variety of reasons that are not directly related to their disease. In the United States, women infected with HIV are disproportionately poor and have an increased frequency of illicit drug use [4], which may cause amenorrhea. One study demonstrated that low socioeconomic class

Lower genital tract neoplasias

The Centers for Disease Control and Prevention (CDC), in 1993, made invasive cervical cancer an AIDS-defining condition [17], and moderate and severe dysplasia were included on the list of conditions whose course or management may be complicated by HIV infection (category B conditions). These changes were made in response to the growing body of research in the early 1990s demonstrating that HIV-infected women have an increased prevalence of cervical dysplasia [40], [41], [42], [43], although a

Contraception

In the HIV-seropositive woman, contraception must play the dual role of birth control and prevention of transmission of HIV and other sexually transmitted infections. The clinician must carefully consider if a contraceptive option is effective, will prevent HIV transmission, will interact with other medications the patient is taking, or will affect the HIV infection itself. Although there is a high correlation between HIV-RNA levels in the blood and HIV in cervico-vaginal secretions, the

Surgical complications

Women with HIV may be at risk for an increase in gynecologic surgery for a number of reasons. One longitudinal cohort study reported that women living with HIV are more likely than seronegative controls to have a hysterectomy, and that this was most often done for cervical neoplasia [171]. Other studies demonstrated a trend toward more tuboovarian abscesses, which often require surgical intervention, among women with pelvic inflammatory disease who were HIV infected [172], [173]. There is a

Osteopenia and osteoporosis

Because of the improved prognosis, and because 5% to 10% of new HIV infections in the United States are currently in people older than 50, the population of seropositive people is aging. Disorders of bone mineral density appear to be more frequently seen in people living with HIV, and so the clinician caring for seropositive women needs to pay special attention to assessing and modifying their patients' risk factors for osteoporosis as well as screening for and treating it.

Initially the

Fertility

As the population of HIV-infected individuals in this country has shifted from primarily gay and bisexual men to heterosexuals of childbearing age, the number of seropositive women contemplating pregnancy has drastically increased. Referrals to gynecologists caring for HIV-infected women are sometimes made by infectious disease specialists caring for men who, with their partners, plan to start a family. In a survey of 2864 HIV-seropositive adults, almost one third expressed a desire to have

Sexually transmitted infections

The treatment of most sexually transmitted infections is similar in HIV-infected and noninfected women [220]. Only differences in treatment will be discussed here.

Herpes simplex virus-2 infections affect 50% to 90% of HIV-infected individuals worldwide [221]. The CDC in 1993 added a herpetic lesion present for at least 1 month's duration to the list of AIDS-defining illnesses [17]. HIV-infected women tend to have more herpes simplex virus (HSV) infections of increased severity, with an

Summary

We have made great strides in understanding the management of the many gynecologic conditions that affect HIV-positive women with an increased frequency. As the HIV-infected woman's life expectancy continues to lengthen, we will need new treatments for recurring conditions such as lower genital tract neoplasias. We have much to learn about the interaction between sex steroids, HIV infection, and the immune system. As our knowledge grows, we will be better equipped to counsel women about

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