Many women living with HIV (HIV+) experience menstrual changes (changes in their periods). It is important to discuss any changes with your health care provider.

The changes HIV+ women may experience include:

• Irregular periods:
  • Different in frequency (how often)
  • Different in duration (how long)
  • Different in amount (lighter or heavier)
• Missed periods
• No period for more than 90 days (amenorrhea)
• Spotting (spots of blood between periods)

Studies have found that menstrual irregularities (changes to your menstrual cycle) are less common if you have a high CD4 cell count and are taking HIV drugs. Menstrual irregularities are more common if you have a low CD4 cell count or high viral load or are significantly below your ideal body weight.

We are not sure exactly how HIV affects women’s menstrual cycles. However, we do know that, as HIV progresses, changes in your immune system can affect the way your body makes and maintains levels of different hormones including testosterone, estrogen, and progesterone. Changes in the amount of estrogen or progesterone could result in a number of menstrual changes for HIV+ women.

Research has shown that women with more advanced HIV disease (CD4 counts below 200), were more likely to have irregular menstrual cycles. Some of the factors that are more likely to occur in women with advanced HIV (wasting and loss of body fat, anemia, nutritional problems) can also lead to menstrual changes because they affect the hormones that control your menstrual cycle. It is important to know that these same issues also affect the menstrual cycles of women who are HIV-negative. For example, women with very low body fat (e.g., elite athletes), women with chronic illnesses not related to HIV, and women with low iron (one cause of anemia), are more likely to have irregular periods or no periods at all.

Because there are many possible reasons for menstrual changes, it is very important to have regular check-ups with your women’s health care provider (often known as a “gynecologist” or “GYN”) and to discuss any changes to your menstrual cycle.

Women living with HIV are more likely to be infected with the human papilloma virus (HPV), which can cause cervical cancer. Therefore, it is recommended that HIV+ women get a Pap test (also called a Pap smear) every six months in the year following the HIV diagnosis. If the results of both of those tests are normal, then they should have one Pap smear every year after that. HIV+ women with symptoms or who have had dysplasia (abnormal cells in the cervix) in the past should receive a Pap smear every six months until they have two normal tests in a row; then they can go back to tests every year. For more information about pap tests and gyn care, see our info sheet on Caring for a Woman’s Body: What Every Woman Should Know about the Care and Prevention of GYN Problems.

Cervical cancer takes years to develop. Often women who have cervical cancer (and have not had a Pap test) do not know they have it until it is quite advanced. This is why getting a Pap test done regularly is so important.

If you miss two or more periods in a row, have heavy bleeding, or have bleeding between periods, see your women’s health care provider for a pelvic examination, Pap smear, and blood tests. These blood tests may check your red blood cell and platelet counts as well as your estrogen and progesterone levels. They will likely test for pregnancy and common sexually transmitted infections (like Chlamydia) that can affect your reproductive system. Your health care provider may also use additional tests such as ultrasound (sonography) to check for causes of irregular periods.

Possible causes for irregular periods include:

• Ovarian cysts
• Uterine fibroids
• Pregnancy
• Opportunistic infections
• Unwanted weight loss
• Pre-menopause or menopause

• Pelvic inflammatory disease (PID): Untreated infections in your vagina or cervix can sometimes lead to heavy bleeding, bleeding between periods, or bleeding after sex. This type of bleeding may signal a complication like PID, which can threaten your health and ability to get pregnant.
• Cervical dysplasia or cervical cancer: Bleeding after having vaginal sex (and not being on your period at the same time) or bleeding between periods (spotting) may be signs of cervical dysplasia or cervical cancer. Cervical dysplasia refers to abnormal cells that can become cancerous; therefore these cells are often called pre-cancerous. It is important to act quickly, see your health care provider, and have a full exam.
• Street drugs: Using recreational or street drugs can lead to missed periods or periods that stop altogether. Drug use can also lead to stress, poor nutrition, and severe weight loss, all of which can cause missed periods. Street drugs that may cause menstrual changes include:
  • Heroin
  • Opiates
  • Methadone
  • Amphetamines
  • Marijuana (more than several joints a day)
  • Cocaine
• Prescribed and over-the counter drugs: Prescribed and over-the counter drugs can also change your menstrual cycle in the following ways:
  • These drugs may cause irregular periods
    • Reglan (metroclopromide)
    • Tricyclic antidepressants (Elavil or Tofranil)
    • Phenothiazines (Mellaril, Compazine and Thorazine)
    • Atypical antipsychotics (Clozaril, Zyprexa, Risperidone, Invega)
  • Some birth control methods can cause irregular periods, initial heavy bleeding, or eventual loss of periods
    • Depo-Provera injection
    • Birth control pills containing only progestin, no estrogen
    • Mirena intrauterine device (IUD)
    • Paragard IUD (“Copper T”)

When dealing with menstrual problems, your provider will likely:

1. Treat any underlying infections, cervical disorders, or cysts
2. Address any nutritional problems (e.g., low iron), anemia, or unexplained weight loss
3. Review all the drugs, vitamins, and supplements you are taking (including medications for HIV and HIV-related conditions, street drugs, and birth control pills)
4. Suggest hormonal contraceptives such as birth control pills if there is a need to restore balance to your hormones and regulate menstrual cycles; however, it is important to know that some hormonal contraceptives interact with HIV drugs
5. Discuss any non-prescription remedies for menstrual symptoms that you may be taking, like herbs or dietary supplements. It is important that you be careful with any herb or food that has estrogen-like qualities, like soy, which may contribute to menstrual irregularities. Common supplements taken for menstrual problems include:
   • Omega-3 fatty acids: For menstrual cramps, bloating, swollen breasts, and mood changes
   • Magnesium: For cramps and irritability
   • Vitamin B complex or calcium: For bloating
   • Vitamin E: For hot flashes or swollen breasts
6. Try to get enough sleep and regular physical activity. Your provider may also suggest some alternative therapies such as acupuncture, and/or yoga to provide some relief from pre-menstrual symptoms.

Even though menstrual problems are common, suffering with them is not a normal part of HIV. In most cases, it is possible to find the cause of your symptoms and to treat or manage the problem. Try to keep track of the start/end dates of your periods each month. It is important to get regular exams, including annual Pap smears, as part of your routine health care, and to report any changes in your menstrual cycle to your health care provider.