People with HIV are now living nearly as long as those without it. This means more are reaching menopause, yet HIV care and menopause management rarely overlap.

The result: missed conversations and clinical uncertainty. Does menopause present differently in women with HIV? Is hormone therapy safe with antiretrovirals? And whose job is it to talk to patients about this?

Too often, no one does. In a small Canadian study, less than half of the women aged 35 years or older with HIV said they had discussed menopause with a healthcare provider.

“Many general practice clinicians report discomfort managing menopause in women with HIV,” said Sara Bares, MD, an HIV specialist and researcher at the University of Nebraska Medical Center in Omaha, Nebraska. General clinicians may know less about drug interactions and comorbidities, while infectious disease specialists lack training in menopause care.

When those conversations do happen, they matter. In the Canadian study, those women who discussed menopause with a provider were three times more likely to start hormone therapy, which early data suggest offers protective benefits, such as reduced hot flashes and improved bone and cardiovascular health.

That signal has fueled a wave of research on menopause and HIV, spanning basic questions on timing and progression to emerging work exploring links with the gut and vaginal microbiome.

What to Know Right Now

People who experience menopause with HIV typically reach this stage earlier than their HIV-negative peers — by about 3 years. In most studies, the transition occurs between 48 and 50 compared with 52.5 in the general US population.

Menopause before 45 appears more common among those with HIV. According to Bares, several factors increase the risk, including very low CD4 counts (< 50 cells/mm³), hepatitis C co-infection, smoking, and socioeconomic factors. Given this range of associations, it’s not clear if early menopause is due to HIV itself or other confounders.

When symptoms emerge, diagnosis can be tricky. “Hot flashes and night sweats can also be symptoms of advanced HIV or poorly controlled HIV,” Bares said. For some, the experience is emotionally loaded. “As they were transitioning into menopause, they started having these symptoms, and they kind of flashed back to their early days of their HIV diagnosis, which was very traumatic for them.”

The first step: Confirm that HIV is well controlled, she said. If labs are stable, clinicians should broaden the differential to the menopausal transition and offer reassurance.

Emerging data also suggest women with HIV may carry a heavier symptom burden, including more vasomotor symptoms, sexual dysfunction, and mood changes, though findings are inconsistent. “These symptoms have been associated with reduced medication adherence and poorer cognitive performance,” Bares said.

Treatment Evidence So Far

For most patients with HIV, menopause treatment looks much like it does for those without HIV: estrogen therapy, with progesterone when indicated.

So far, the data are reassuring. Hormone therapy doesn’t appear to raise fracture risk, and a recent randomized trial showed that vaginal estrogen significantly improved genitourinary symptoms without disrupting HIV control or the vaginal microbiome.

Cardiovascular risk remains a concern. Patients with HIV “have about a twofold increased risk of cardiovascular disease and diabetes — and then menopause, with the decline in estrogen, also increases [cardiovascular] risk,” Bares said. “It’s unfortunately a synergistic effect.”

Encouragingly, a 2022 study found that women with HIV who used hormone therapy had a 43% lower prevalence of plaque and slower progression of atherosclerosis than nonusers — a pattern similar to that seen in women without HIV.

Timing is critical. Hormone therapy is safest when started before age 60 and within 10 years of menopause onset, said Brandilyn A. Peters-Samuelson, PhD, an epidemiologist at the Albert Einstein College of Medicine in Bronx, New York. Her work suggests that atherosclerosis may accelerate during the menopause transition — an important consideration in a population already at elevated cardiovascular risk.

More answers are on the way. Bares is now enrolling middle-aged women with HIV into a large trial — the HoT trial. Participants receive transdermal estrogen, with or without progesterone, for 12 weeks.

Hormone therapy remains underused in this population, Bares said. For women without contraindications, it should be discussed as it would be for any patient. “We would stay away from hormone therapy in women with HIV for the same reasons we would stay away from hormone therapy in women without HIV,” she said. “But the risks aren’t more so, as far as we know, in people with HIV.”

One caveat: coordinating treatments matters. Some antiretrovirals — particularly pharmacologic boosters — can lower estrogen levels. “But the estrogen can be titrated,” Bares said. So it’s not a contraindication.

About a quarter of the 1.2 million people living with HIV in the US are women, with many being middle-aged or older. Bares stops short of recommending hormone therapy for all.

“It’s a hard one,” she said. On one hand, experts want trial data on dose, efficacy, and safety. On the other, they don’t want patients to suffer in the meantime.

Research and Resources on the Horizon

Even fundamentals of menopause can vary in women with HIV. The standard definition — 12 consecutive months without a period — doesn’t always hold.

“Women with HIV may have extended periods of amenorrhea that aren’t related to menopause,” Peters-Samuelson said. In studies, some participants report 12 months without menstruation only to resume bleeding later, complicating diagnosis. Her team is studying whether anti-Müllerian hormone could be a more reliable marker.

The HoT trial seeks to confirm observational findings and examine new questions, too: Does hormone therapy safely ease symptoms? And how does it affect broader health? Researchers are tracking hot flashes, mood, sleep, quality of life, and cardiovascular and bone markers. Some participants are wearing physiologic hot flash monitors, and investigators are collecting gut and vaginal samples.

“We’ll look at gut microbiome diversity, composition, and functional potential,” Peters-Samuelson said, as well as whether microbiome changes correlate with symptom relief or shifts in cardiometabolic biomarkers. The study will also assess whether hormone therapy improves vaginal health — a key factor in sexual health and infectious disease transmission. Data collection is expected to wrap in September 2027.

For clinicians seeking guidance now, a new website, Her & Now, can help.

It’s an “accessible, evidence-based hub” — developed by Bares and others and funded by the National Institutes of Health’s Office of AIDS Research and Office of Research on Women’s Health — for all providers looking to learn more about menopause and HIV. “Our goal is to make high-quality menopause care feel achievable in everyday practice — not just in specialty clinics,” Bares said.