Perspective: Information, Inspiration and Advocacy for People Living with HIV/AIDS

EH4S dlii.]uIe;t]e la a a1-] m Te rapy.. ___________________

Hormone Replacement Therapy
The use of hormone replacement therapy and hormonal contraceptives is a difficult issue for women living with HIV.

Advocates have battled for studies of possible interactions between HIV therapies and
oral contraceptives (OC). However, it is not
oral contraceptives (birth control pills), but
the use of other hormonal therapies (such
as implants and injections) that needs addressed. For many women with HIV, pregnancy plays little part in deciding on therapies, which are used to manage menstrual
flow, menopause and pre-menstrual syndrome (PMS), or to affect body composition. These uses, as well as the impact of
HIV therapies, are not addressed in simple
oral contraceptive drug interaction studies.
HIV has an impact on hormone levels; in
men, testosterone is often deficient and replacement therapy can increase energy levels, manage depression and promote weight.
In women, abnormal menstrual cycles,
weight loss, gynecological infections, headaches and fatigue are common and may relate to decreased estrogen. Estrogen supplementation is not a simple choice, as it can
increase the risk of breast and endometrial
(the membrane lining the uterus) cancers.
The issue of abnormal menstrual cycles and
premature menopause in HIV positive
women has been debated, and studies com
* paring menstrual cycle differences in HIVpositive and HIV-negative women have
shown conflicting results. Many doctors
view abnormal menstrual cycles as an inconvenience rather than a serious medical
* condition and thus don't address them aggressively. However, a recent study reported. the use of hormone replacement in HIVpositive post-menopausal women predicted
survival. This implies hormonal regulation. may have broader health implications than
* previously assumed for women with HIV.
* There are also questions about the relationship between hormone levels and the immune system, drug metabolism and body
composition. Little is known about how hormonal therapies used by women interact
with anti-HIV drugs. The few oral contraceptive studies done, have only looked at
how HIV drugs and contraceptives affect the
blood levels of one another. For instance,
nelfinavir (Viracept@) decreases the levels
of ethinyl-estradiol (a birth control pill) by
50% and some doctors suggest women
double their dose to prevent pregnancy.. What does this mean if ethinyl-estradiol. (which contains, estrogen and progestin) is
used for hormone replacement therapy
rather than birth control? One concern is

that a woman who doubles the dose may
increase her risk of cancer. But the risk of
cancer may be less when hormone therapy
is used to resolve existing deficiencies, as
opposed to boosting otherwise normal levels to prevent pregnancy. The reverse issue
also exists; anti-HIV drugs may be metabo* lized differently in the presence of birth control medications. What are the interactions
and effects of hormonal contraceptive or
replacement therapies, such as the implants
or injections, when used with anti-HIV drugs?
I Replacement may also impact body compo-. sition changes and wasting. For instance,
* Depo-provera, an injectable synthetic hormone administered every 3 months, can in-. crease body weight about5 pounds per year.
One study found that over 5 years, women
* gained 25 pounds on average, indicating that
the weight gain is not transient. As with. Megace, this weight seems to be primarily
fat, not muscle. Injected once quarterly,
Depo could be a simple, dual-use alternative to therapies like Megace for weight
maintenance.
Research specific to hormone levels and the. effects of hormone replacement therapy on
women living with HIV is overdue. The
better our understanding of the impact of
hormonal imbalances on the immune system, drug metabolism and general health,
the more effective women with HIV and their
health care providers can be in addressing
these issues. N

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