Menstrual health and HIV

Can HIV affect the menstrual cycle?

Possibly. Many people experience changes in their menstrual cycles throughout their life. These can include irregular periods, changes in menstrual flow, and worsening of premenstrual symptoms. These can happen whether or not you have HIV.

Most menstrual changes reported by people living with HIV don’t seem to have a direct link with the virus. However, lots of studies have shown that menstrual changes are more common in people living with HIV.

For example, it seems that people living with HIV are more likely to experience missed periods (amenorrhoea). A recent study found that 24% of women with HIV had experienced amenorrhea for a year or more at some point in their life, compared to 13.3% of women who did not have HIV. 

In this study, missed periods were more common in people who had a history of drug use and who were currently experiencing food insecurity. However, even once these things had been considered, the risk of prolonged amenorrhea was still much higher in women living with HIV.

As well missing periods, there’s also some evidence that women living with HIV experience worse premenstrual symptoms compared to the general population.

Why might HIV affect periods?

The exact reasons for the period changes seen in people with HIV are not clear. It seems that HIV probably affects periods directly, especially if you have, or have ever had, a low CD4 count.

But we also know that other risk factors, such as low body weight, smoking, emotional stress, and substance use can affect periods. Many people living with HIV will have a combination of some or all of these risk factors.

Some studies have suggested that certain types of HIV medication could play a role, but there isn’t clear evidence showing a link. It may be the case that older types of medication were more likely to disrupt your period than the ones that most people take now.

Changes to your period can be a sign of an underlying problem. You should always consult your doctor if you experience unexpected menstrual changes. There might not be anything wrong, but it's a good idea to get checked out to see what the cause might be. More detailed advice is available on the NHS website.

Is a missed period a symptom of HIV?

No, a single missed period is not a sign of HIV.

The symptoms of recent HIV infection are the same in men and women, with the most common being fever, swollen glands, muscle aches and tiredness. A more detailed list of the symptoms associated with HIV seroconversion can be found on another page.

There are many reasons why someone may miss their period, including pregnancy, travel, stress, sudden weight changes, and doing lots of exercise.

Any effect HIV has on menstruation is likely to relate to long-term, chronic infection.

Can HIV be transmitted via contact with menstrual blood?

Menstrual blood touching unbroken, healthy skin is not a risk for HIV transmission. If it comes into contact with broken skin or is swallowed, then HIV transmission is possible but it’s still unlikely.

Due to the effectiveness of HIV treatment, the menstrual blood of someone living with HIV who is taking their antiretroviral medication as prescribed could well have no detectable virus (Undetectable = Untransmittable).

The small number of case reports documenting HIV transmission via exposure to blood involved a significant amount of blood from an HIV-positive person coming into contact with open wounds on another person’s skin.

Does menstruation raise the risk of HIV transmission to sexual partners in other ways?

If a person living with HIV is not taking antiretroviral treatment, levels of HIV in their vaginal fluid are likely to be higher during menstruation.

Several studies have shown that viral load in the female genital tract (which includes the vagina) can vary during the menstrual cycle.

This includes a 2004 study which found that viral load levels in cervico-vaginal fluid tended to peak at the time of menstruation and fall to the lowest level just before ovulation, usually midway through the cycle.

This would raise the risk of HIV transmission during periods if preventative methods (such as condoms or pre-exposure prophylaxis – PrEP) weren’t being used.

However, due to the effectiveness of HIV treatment, the bodily fluids of someone living with HIV are likely to have no detectable virus (Undetectable = Untransmittable).

One thing to note is that viral load in vaginal fluids may fall more slowly than in non-menstrual blood. This means they may have a detectable viral load for a few months after the viral load has become undetectable on blood tests.

If you’re unsure, condoms, dental dams, and PrEP are all options that reduce the risk of HIV infection during sex with a person living with HIV who is menstruating.

Are women at greater risk of HIV during menstruation?

The bleeding you experience during a period itself does not increase the risk of acquiring HIV.

However, hormonal changes during periods are believed to increase risk. The biology of the vagina and cervix mean that women, especially adolescents and older women, are in general more vulnerable to HIV and sexually transmitted infections (STIs) than men.

A 2015 study in monkeys concluded that immune protection is at its lowest mid-cycle, providing a “window of opportunity” for infections to enter.

In addition, researchers following a group of 37 HIV-negative female sex workers in Nairobi, Kenya, found an association between menstruation and biological factors that could mean increased susceptibility to HIV infection. The authors concluded that a better understanding of the hormonal cycle on the vagina is needed to work out exactly how it influences HIV sexual transmission in women.

You should always consider using barrier methods such as male (external) and female (internal) condoms to provide the best protection from STIs including HIV, regardless of where you are in your menstrual cycle.

Can people living with HIV use hormonal contraception to suppress menstruation?

People living with HIV can use hormonal contraception to suppress (stop) their periods, just like anybody else.

However, it is important to take HIV treatment into account when choosing such options, as there are possible interactions between anti-HIV drugs and hormonal contraceptives that mean the contraception may not work.

Contraceptives that can suppress periods include:

• contraceptive injections – their reliability is not normally affected by antiretrovirals.
• intra-uterine devices/systems (IUD/S) –  their reliability is not normally affected by antiretrovirals.
• progestogen-only pills (POP) – some anti-HIV drugs can reduce their effectiveness.
• combined pills - some anti-HIV drugs can reduce their effectiveness.
• contraceptive implants – some anti-HIV drugs can reduce their effectiveness.

The antiretrovirals that have the potential to affect the effectiveness of hormonal contraceptives include:

• atazanavir (Reyataz, also in Evotaz)
• cobicistat (Tybost)
• darunavir (Prezista, also in Rezolsta and Symtuza)
• efavirenz (Sustiva, also in Atripla)
• elvitegravir (Genvoya and Stribild)
• etravirine (Intelence)
• fostemsavir (Rukobia)
• nevirapine
• ritonavir (Norvir).

This is because both the anti-HIV drug and the contraceptive are processed in the liver by the same enzymes, so the contraceptive is processed faster than usual. As a result, levels of the contraceptive hormones may be too low to always prevent a pregnancy. The anti-HIV drugs will continue to be effective and work well. 

When selecting contraceptive methods, people living with HIV should always speak to a doctor or pharmacist to ensure compatibility with their antiretroviral therapy regimen. This is also important for emergency contraception (the ‘morning-after pill’).

Does contraception increase women’s risk of HIV?

Observational research studies in the past had suggested a possible increased risk of HIV for women using progestogen-only injectable contraception, such as the DMPA intra-muscular injection, also known as Depo-Provera.

However, a large study with a more reliable methodology, conducted in four African countries in 2019, found no significant difference in risk of HIV infection among women using hormonal or non-hormonal long-acting reversible contraceptive methods (implants, injections or IUDs).