As well as affecting your immune system, HIV may affect your hormonal system. You may experience menstrual changes, especially if you have a low CD4 cell count and/or a high viral load.

Some of the menstrual changes you may experience include:

• long intervals between periods
• missed periods without pregnancy.

Tell your doctor if you notice any changes to your periods. It could mean that you need to consider starting to take HIV treatment. Changes in your menstrual cycle can also be a symptom of other health problems. But remember that a missed period might also mean that you are pregnant.

Abnormal bleeding (for example, after sex), bleeding after the menopause, or very heavy periods should also be reported to your doctor. Heavy periods can be caused by several factors, including fibroids (growths that develop from the smooth muscle layer of the uterus). If left untreated, the blood loss from heavy periods could lead to anaemia (a lack of red blood cells) and other health issues. It is important to talk to your healthcare team if symptoms persist.

HIV can affect your body’s ability to produce the hormones oestrogen and progesterone. This can affect your fertility (your ability to become pregnant) or lead to an early menopause (and the ending of your fertility), particularly if your CD4 cell counts are low.

With effective treatment, many women with HIV are likely to have a normal lifespan, meaning they will have a normal menstrual cycle and go through the menopause – the ending of the menstrual cycle (periods) – something that happens to all women in middle-age.

In the general population, women of African ethnicity and women who inject drugs are likely to have an earlier menopause than other women. There is also some evidence that women with HIV may start the menopause a few years earlier than women without HIV, especially women with a low CD4 count.

Hormone replacement therapy (HRT) can be prescribed to prevent or lessen some symptoms of menopause, or to treat the early onset of menopause. HRT is generally not used as a long-term treatment because it may increase the risk of developing other conditions such as breast cancer.

HRT can be taken with HIV treatment; ask your doctor if there are any interactions between HRT and the anti-HIV drugs you are on. Ritonavir, an anti-HIV drug, can lower levels of some HRT drugs, for example, and your dose may have to be altered.

HIV clinics don’t provide HRT, so you will need to have it prescribed by your GP or another doctor.

If you have questions about symptoms of the menopause, or possible interactions between treatments, talk to your healthcare team. You could also ask about attending a menopause clinic. 

Osteoporosis – weakening of the bones through loss of bone density – is more common in all women who have gone through the menopause, because of the high level of hormonal changes which occur during menopause.

People with HIV tend to have lower-than-normal bone density. It’s not entirely clear why this is, but it seems likely that it is caused both by HIV itself and by the effects of treatment, as research suggests that certain anti-HIV drugs may cause bone loss. (You can find out more about different types of drugs in NAM’s booklet Anti-HIV drugs.) There’s some evidence that women with HIV who have a ‘co-infection’ with hepatitis B or C can have an increased risk of reduced bone density.

Bone mineral density can be measured painlessly with a scan known as DEXA (dual energy X-ray absorptiometry). You may have been offered this scan as part of your HIV health monitoring (it is part of the standard monitoring recommended for women aged 65 and over, or aged 50 or over if you have other risk factors, such as co-infection with hepatitis). If you haven’t, you are menopausal and worried about your bone health, you could ask to have one done.

There are a number of things you can do to reduce loss of bone density and its effects. These include taking some weight-bearing exercise (such as walking, running, or climbing stairs) and having a healthy diet, with plenty of calcium and vitamin D. Oily fish, liver, fortified spreads and cereals, and egg yolks are a good source of vitamin D (as is sunlight); calcium can be found in milk and other dairy products, leafy green vegetables such as kale and broccoli, beans such as soy and baked beans, nuts, sesame seeds and many types of fish, such as salmon and sardines.

Some women may be advised to take calcium supplement tablets, particularly if your diet does not include many of the foods containing this nutrient. Taking too much of a supplement can be harmful, so it is a good idea to talk to someone at your HIV clinic, or your GP, before you start. You could also ask to talk to a dietician, to find out if you can adapt your diet to increase the calcium and vitamin D it provides. There is no clear evidence that vitamin D supplements help reduce the risk of bone loss in people with HIV, but it does help your bones absorb calcium.

Smoking and heavy drinking can increase your risk of osteoporosis.

Your healthcare team can give you more advice on changes to your treatment and lifestyle that may help. There are also some treatments available to improve bone density and they can talk to you about those if necessary.

The Nutrition booklet in this series provides information on food, nutrition, exercise and HIV, and could be a good place to start if you have questions about any of these issues.

Some reproductive health (gynaecological) problems happen more often in women with HIV, and can be more severe, or harder to treat.

Regular screening for sexually transmitted infections (STIs) is an important part of your health care. Sometimes, you will not have any symptoms if you have an STI, so regular check-ups are important, especially if you have had unprotected sex. As well as the risk of illness, including long-term damage to your own health, having an STI can increase the risk that you will pass on HIV during unprotected sex. You can find out more about this risk, and how to avoid it, in NAM’s booklet HIV & sex. This booklet also has information on the diagnosis and treatment of STIs.

If you have an infection that can be transmitted sexually, your sexual partners will need to have a sexual health screen and any necessary treatment before you have sex again so that they can also have any infections diagnosed and treated.

Pelvic inflammatory disease (PID) is a bacterial infection that can occur in a woman’s upper genital tract, including the womb, fallopian tubes and ovaries. It can be caused by some untreated STIs such as gonorrhoea and chlamydia, as well as other bacteria and infections such as tuberculosis.

It is always a serious condition, especially if you also have HIV. Having untreated PID, or having it repeatedly, can make you infertile (unable to get pregnant).

Symptoms include:

• pain in the lower part of your stomach area
• unusual vaginal discharge
• pain during sex, felt deep inside your pelvis
• fever
• vomiting
• unusual bleeding from the vagina (between periods or after sex).

A general sexual health check-up will include tests to see if you have gonorrhoea or chlamydia. You may need a scan to see if PID has caused any cysts or abscesses, or an examination called a laparoscopy. This procedure involves a surgeon making a small cut in the stomach to insert a tube that allows them to see inside the abdomen and the pelvis. It is done under a general anaesthetic.

If you have PID you will be treated with a combination of antibiotics. Getting help and treatment early is important to reduce the risk of long-term pain and recurrence of PID.

The human papillomavirus (HPV) is a family of different strains of virus. HPV is sexually transmitted and very common – most people will have it at some point in their life. It is possible for your body to clear HPV infection itself, but women with HIV are much less likely than HIV-negative women to do so. A vaccine against HPV is available.

Some strains of this virus can cause abnormal cervical cells to develop, which can lead to cervical cancer if not treated. Women living with HIV, especially if you are over 40, have a higher chance of developing abnormal cervical cells caused by those strains of HPV than women without HIV. Treatment for abnormal cervical cells is highly effective, provided they are detected early.

Make sure you have regular cervical screening (smear tests) to check for these cells so that you can receive prompt treatment to remove them. There are no symptoms of having this sort of HPV.  All women with HIV should have a cervical screen soon after they are diagnosed with HIV, again after six months and then every year after that. This is more often than is recommended for women without HIV, who are offered this test every three years. Your GP will need to know about your HIV status to ensure you are offered annual screening. Talk to your clinic staff if you would like them to arrange this with your GP. If you don’t have a GP, or haven’t disclosed your status to them, talk to staff at your HIV clinic about where to have regular cervical screening.

Other strains of HPV can cause genital warts, but these don’t always leave visible signs. They can also be detected by cervical screening and treated by applying a cream, or by freezing or burning them off.

Genital herpes is caused by two types of herpes simplex virus (HSV), type 1 and type 2. Both types are highly contagious and can be passed easily from one person to another by direct contact. Once you are infected, the virus remains in your body for life, although you may not have any symptoms much of the time.

Genital herpes attacks can happen more often, last longer and be more painful if you have HIV, especially if your immune system has been weakened. The antiviral drug aciclovir can help shorten the duration of herpes episodes. If you are getting regular episodes of herpes, you may want to consider taking aciclovir every day to help prevent this.

Although there is an increased risk of fungal infections if you are HIV positive, such as vaginal candidiasis (thrush), treatment works well.

Bacterial vaginosis is an overgrowth of bacteria in the vagina that occurs in many women, regardless of their HIV status. Its symptoms can include a discharge which has a ‘fishy’ odour, but many women have no symptoms at all.

It’s not strictly an STI, but the risk of getting it is increased if you have a new sexual partner, or multiple sexual partners; you are also more likely to get it if you are pregnant. Washing the vagina (douching) is a common cause of bacterial vaginosis. Douching and using scented soap or vaginal deodorant can upset the balance of bacteria in the vagina. Smoking, using bubble bath and having an intrauterine device (IUD) fitted can also increase the risk of bacterial vaginosis.

It can be treated with antibiotics. If bacterial vaginosis is left untreated, it can cause more serious symptoms and can lead to pelvic inflammatory disease and infertility. It can increase the risk of mother-to-baby transmission of HIV and of passing on HIV to a sexual partner.