HIV and Sexual Function in Women Over 50

I recently wrote a "stand-up" blog (pun intended) on erectile dysfunction in HIV-positive men over age 50, which caused a few tongues to wag. So in order to present "fair balance" between the genders, this "dictates" (oh my) that I must blog on HIV-positive women over 50 and sexual function, or lack thereof.

In preparing this blog, I was amazed (as I always am) at the paucity of research literature on this seemingly hot topic. Where are the articles on women's sexual function -- and the sexual dysfunction drugs in the development pipeline -- as there are for men?

During my review of the literature, I was able to find an article by Tracey Wilson et al in the Journal of Acquired Immune Deficiency Syndromes (2010) entitled "HIV Infection and Women's Sexual Functioning," which sparked my attention. The authors reported findings from the prospective Women's Interagency HIV Study (WIHS).

The WIHS enrollment was phenomenally large, with approximately 3,000 matched (by age, race, ethnicity, recruitment site, risk factors and number of partners) HIV-positive and HIV-negative women. Data on sexual function were collected (as a small part of this ongoing study) with a survey tool called the "Female Sexual Function Index" (FSFI). The FSFI is a 19-item self-report survey capturing multiple domains such as sexual arousal and desire; lubrication; orgasm; and pain during intercourse. It also includes questions on other domains such as satisfaction or dissatisfaction with orgasm, with overall sexual life, and within sexual relationships. Information was also solicited on depression -- via the Centers for Epidemiological Studies Depression Scale, a 20-item survey tool -- as well as use of antidepressants, alcohol and drugs, menopausal status, use of hormone replacement, antiretroviral therapy, adherence and viral load.

Of particular note is that the characteristics of the study population included my people: women over 50. There were 311 HIV-positive women and 89 HIV-negative women over age 50. Finally, researchers are showing interest in women, particularly aging women. It's about time!

In the discussion, the authors noted that the burden of sexual problems is significantly higher among HIV-positive women compared with HIV-negative women. These results seem to be in sync with the data from the 1992 National Health and Social Life Survey on sexuality among younger adults in the U.S. This survey suggested that among sexually active women aged 18 to 59, approximately 40% reported symptoms of sexual dysfunction over a 12-month period. Hello-o, people! Something is wrong.

Furthermore, FSFI scores in the WIHS study were associated with increasing age, menopause, symptoms of depression and relationship status. CD4 count and age were statistically significant factors. The average FSFI score among HIV-positive women was significantly lower than that of the HIV-negative group (13.8 versus 18.0, respectively, on a scale of 0 to 36).

So based on the results reported in this article, how do we as clinical practitioners proceed with our HIV-positive women over 50 who report sexual dysfunction? Do we tell them they are just "frigid," as women in general were told decades ago? Or do we suggest to them that they shouldn't be having sex anyway because they are HIV positive and over 50? Oh, no we don't. As I similarly assert in my blog on erectile dysfunction in HIV-positive men over 50, we must assist them in being healthy sexual beings.

Some of the causes of sexual dysfunction in women can include the following:

• psychological conditions, including depression and poor self-esteem

• body habitus changes from aging, drug use and antiretroviral use

• effects of aging

• menopause status -- premenopausal, menopausal (cessation of menses for 12 months) or post-menopausal

• substance use -- prescription and recreational

• comorbid conditions such as diabetes, thyroid disorder, vascular disease and hypertension

• side effects of medications such as antidepressants, hormone replacement and beta blockers

• CD4 count less than 200 cells/mm³.

So what can we do as care providers?

• Have an open dialogue with your patient. Ascertain how the patient feels about herself and/or her relationship(s), if any.

• If you are not the health care provider, then refer for a diagnostic workup that includes an evaluation for hormone levels (estrogen, follicle stimulating hormone, luteinizing hormone and thyroid function panel).

• Treat comorbidities, such as hypertension, diabetes mellitus and depression.

• Discuss potential side effects of treating comorbidities.

• Discuss drug-drug interactions between all medications, including antiretroviral medications for the treatment of HIV.

• Discuss pharmacologic intervention for vaginal dryness with over-the-counter products such as Replens or other water-soluble lubricants, hormone replacement and antidepressants.

• Encourage relationship counseling if her relationship with her significant other is in need of a tune-up or is a certifiable hot mess.

• Encourage clients to participate in clinical trials -- although Boehringer Ingelheim failed to win U.S. Food and Drug Administration approval for Girosa (flibanserin) in 2010, there may be other products coming down the research-and-development pipeline.

• Support the community that truly believes women can have sexual dysfunction just like men.

Thanks to Olivia Ford for challenging me to write this blog!