Viremic – Cases in HIV

Announcer:
Welcome to Viremic–Cases in HIV, hosted by Dr. Eileen Scully and Dr. Christopher Hoffmann, both HIV specialists at Johns Hopkins, who explore quandaries in adult HIV care. Each case discussion includes medical history and diagnoses, challenges in care and treatment, and key evidence and guidelines that inform clinical decision making.

Cases are presented as a composite from the hosts’ clinical practice, with all identifying details removed to protect the privacy of patients. Case discussions are for informational purposes only and not offered as medical or clinical practice advice for patients or clinicians. Any mention of specific medications or commercially available products is a description of use only, not an endorsement.

Dr. Eileen Scully:
Welcome to Viremic, a podcast where we discuss all things HIV. I’m Dr. Eileen Scully and I’m coming to you from Johns Hopkins here in Baltimore. Before we begin, if you like this episode, please share it with a colleague and follow us wherever you listen to podcasts. We’d also love to hear what you think. Please leave a comment or send us an email at viremicpodcast@jh.edu, and feel free to leave suggestions for future topics you’d like us to discuss.

For today’s podcast, I am honored to be joined by Dr. Sara Looby. She’s a nurse practitioner and a PhD-trained researcher in the metabolism unit at Massachusetts General Hospital, who has focused her clinical efforts on the care of women living with HIV. Over recent years, her research has made seminal contributions to the understanding of how midlife transitions impact women’s health, spanning metabolic, psychological, vasomotor, and cardiovascular considerations. She is one of the leadership team for the currently enrolling ACTG trial on menopause in women living with HIV and has recently developed the “Her & Now” program. This is an NIH-supported program that worked with women living with HIV to develop educational resources to improve clinician knowledge, comfort, and confidence for providing care to midlife women. On a personal level, I’ve had the opportunity to work with Dr. Looby multiple times over the last few years, and I’m always impressed by the clarity of her communication, the depth of her knowledge, and her commitment to improving the lives of women living with HIV. Welcome Dr. Looby to the podcast.

Dr. Sara Looby:
Thank you for inviting me. It’s a pleasure to be here.

Eileen:
Before we get started, I was wondering if you could share a little bit about why you have chosen to focus specifically on women living with HIV who are in the midlife transition. What drew you to these questions in this population?

Sara:
When I started working in the metabolism unit here at Mass General Hospital in the early 2000s with people living with HIV, I was a nurse practitioner, as you mentioned, and I was working with Dr. Steven Grinspoon helping with the design, implementation, and evaluation of endocrine and metabolic studies. I felt it was important in my role to engage with people living with HIV in the community so I could better understand their perceptions of research, barriers, and facilitators to joining research studies, and then also using this as an opportunity to share findings from published research so that they could help improve their own care and communications with their clinicians. I would take research that we did in our group and published and research studies from around the world on metabolic or cardiometabolic issues in people with HIV, translate the findings into laypersons’ terms, and then go back to these community organizations and have discussion groups. I did this weekly, sometimes monthly, at various HIV community centers across Massachusetts, sometimes New England, and I would come prepared with a topic or an article, and then I would sit and answer questions and engage in discussion with the attendees.

One day, after sharing some information about insomnia or sleep challenges or disruption and people living with HIV, this woman raised her hand. She was typically very quiet, and she was a woman with HIV. She said, “You know, I’m very scared. I’ve been waking up every night in complete sweat. My pajamas are sweaty. My sheets are soaked. The only time I ever recall experiencing this is when I was newly diagnosed with HIV. I’ve had the virus for quite some time now. I’ve been on the same regimen. I’m scared that my medications, my antiretroviral therapy, is no longer working and I’ve developed AIDS.” She was very distressed. I asked her how old she was, and she said she was in her late 40s. I asked her about how long she’d been experiencing this, and she said a couple of months. Then another woman in the group raised her hand and said, “Geez, you know, the same thing’s happening to me.” She was reassured by this, that somebody else was experiencing this. I did not have a whole lot of knowledge on menopause in general. It was not my area of expertise. But I remember saying, “this sounds like maybe you’re in menopause. When I come back next week, I will come with an article or 2 describing exactly what might be going on with women with HIV during menopause and we can figure out what I can learn. In the meantime, maybe you can call your doctor and set up an appointment. Don’t be afraid. The first step is getting your CD4 count, HIV viral load done.”

I did a lot of literature research, and I couldn’t find an article. I found one. It was a brief communication in a journal that talked about some preliminary data talking about menopause and women with HIV and how this was an emerging phenomenon. Remember, this was in the early 2000s before we had a handle or an interest in looking at midlife women’s health in women with HIV. One of the only pieces of literature I came across during that time was an article that was published in an HIV consumer magazine where a woman talked about waking up in the middle of the night in a pool of sweat, essentially saying she thought for sure her HIV viral load was through the roof and her CD4 count was low. Then she came to learn that it was menopause. At that moment, I said to myself, “This is a big problem.”

Women are living longer with HIV than we had anticipated, globally. We had done an incredible job identifying, obviously, antiretroviral therapy, reducing mother-to-child transmission and women living with HIV, and of course, beginning to get a handle on cardiometabolic and comorbid conditions associated with aging, but we hadn’t yet explored menopause to a great extent. That became my first NIH grant submission, and I received a K 23 training grant under the mentorship of Drs. Steven Grinspoon, Jan Schifren, and Hadine Joffe, who were also here at Mass General and menopause experts, and that’s how I entered this research area. It was brought up to me by my interactions and encounters with patients and women living with HIV in the community.

Eileen:
Sara, thank you for sharing that. I have two reflections. The first is, your career has had this real journey from starting at this ground level of education of people living with HIV and direct interaction, and now you’ve taken what you’ve learned from them and are shifting into education of clinicians with your more recent efforts and how your research grew out of the need in the community. That’s a beautiful story.

And the other thing I was reflecting on is as we were talking about the early 2000s when there was so little research, it also wasn’t part of the community discussion either. Now I feel like we’re in a very different moment where, as the New York Times will say, menopause is having a moment. Now we do have more information, still big gaps. But I think in the age where there are a lot of people who are following non-traditional pathways in how they manage these symptoms, as there’s more of a general conversation about menopause, the use of evidence-based techniques to care for women in midlife is really critical.

Thank you for sharing that. For any of our listeners who are thinking about how their career can move forward in meaningful ways, what a beautiful example of how you can take your motivation from the needs of the community.

Sara:
Thank you very much. I feel very lucky to have started my practice in a location where there is a lot of community activism and community organizations. And it, as you mentioned, has been an integral piece of my development as a clinician and a scientist.

Eileen:
Now I’m going to start us off. We’ll do our typical case-based approach for the day. Our amalgam case today is going to be a 53-year-old woman who has a long-standing history of HIV. She is currently well controlled with a fully suppressed viral load on an antiretroviral regimen of dolutegravir and 3TC, and her CD4 count is in the 400s. She’s had hypertension, for which she has been working on diet and exercise and mild hypothyroidism for which she takes levothyroxine. Her most recent labs show that she is euthyroid. She’s adequately supplemented. She is divorced. She has 3 children, 2 in their 20s and 1 who is in high school. She has disclosed her HIV status only to her mother but otherwise does not discuss her HIV with anyone. During the visit, you discuss her current status and get an update on her life in general. She initially tells you that everything is fine.

But as you discuss things a bit more, she reports that she’s been feeling a bit more irritable than usual and has noticed that she does not feel rested in the mornings. With some further questioning, she notes that she is waking up with sweats at night. Sara, at this point in the visit, what kinds of questions would you ask to get a little more information about what could be going on for her?

Sara:
At this point, I would share with her that some of the symptoms that she’s describing, the sweats, the mood changes, the fatigue, which is probably related to her sleep disruption, are not uncommon among women her age, and that they may be related to hormone changes associated with menopause. Next, I would ask her what she knows about menopause, and this would be to establish a baseline understanding of the extent of education on this topic that I would need to provide. Because anecdotally, many women do not have a proper understanding or a comprehensive understanding of what menopause is, despite the fact that it is a relatively hot topic, no pun intended.

Then after that, I would ask her about her menstrual patterns to gauge a preliminary understanding of her potential stage of menopause. I would also take a glance at her chart to see if she has a history of a total hysterectomy or a BSO, which is either partial or total removal of the ovaries, or a partial hysterectomy, a history of uterine ablation, the use of any kind of hormones, including birth control, or any other interventions or medications that may affect her period.

Then once I kind of gather this preliminary assessment, I would move forward with providing a brief overview of what menopause is, its stages and conditions, and then of course some of the symptoms that are associated with it. And I would ask her if she’s experiencing other potential symptoms of menopause, for example, vaginal dryness, pain with intercourse, the abdominal fat concentration or changes in her body composition. Then I think it’s important to acknowledge with her that some of the symptoms and conditions associated with menopause may overlap with conditions and symptoms associated with HIV and commonly experienced by women living with HIV, highlighting that the menopause transition may be more complex and burdensome in women with HIV.

You could do this nicely as a clinician by using depression as an example, to explain that depression is common in many women living with HIV, and that when a woman enters menopause, particularly that perimenopausal stage where you still have a period, but it’s erratic and your hormones are rapidly shifting, that mood instability can occur. When this happens, if you’re going into this menopause transition with a known history of depression, and particularly given that women living with HIV have a higher prevalence of depression and depressed mood compared to women without, that medications or existing therapies for depression at that phase may need to be reassessed, readdressed, and treated in a different way. Then I would conclude by stating that there are other factors that might influence some of these symptoms like fatigue and changes in menstrual patterns, noting that she has hypothyroidism and that symptom or condition may affect her periods in a different way, similar to menopause.

Given that she had HIV, we may need to order additional labs to help determine where she stands with some of her comorbid conditions, particularly the hypothyroidism, to see if maybe it’s her thyroid that needed to be tweaked versus automatically assuming that this is related to menopause.

Eileen:
Sara, one quick follow-up, in your experience, when you start to discuss the possibility of menopause as contributing to symptoms, do you find that women are receptive or do they find it surprising coming from a more general provider or even in the research setting? Is there still this idea that it should be confined to the gynecologist type of a visit?

Sara:
I believe that all clinicians providing any related primary care should always offer resources and discussion about menopause for all women. I would even argue beginning at age 40, because this type of education allows for anticipatory guidance. I don’t know if it’s because I’m a nurse by training, but I am a big anticipatory guidance person. I do Pure Barre and certain teachers will say, “Only going to do this for five more minutes, then we’re going to transition to core.” If somebody doesn’t say that, it drives me bananas because I’m like nervous that I’m going to be stuck doing this plank for an additional minute. So, I’m a big fan of anticipatory guidance. If you start early around age 40 providing guidance, particularly among women with HIV who may enter the menopause transition earlier than women without HIV, this will allow the women to prepare themselves for this transition. This can help reduce anxiety and begin to decipher or understand the overlap between symptoms of HIV and symptoms of menopause and potentially feel more empowered to engage and ask clinicians about menopause during future visits if it’s not brought up.

Eileen:
I completely agree. People who are very anxious about something will sometimes avoid discussing it or engaging with their healthcare providers. So, providing this information gives women the context that maybe this symptom is not that thing that they’re terrified of but is something else and may encourage better communication. By having that framework that this is a possibility, it might not be the scariest thing ever, I do think that can sometimes trigger avoidance.

Sara:
I want to comment on a topic that you had mentioned before about or using the term “all clinicians.” It’s interesting with HIV specialists. In the beginning, HIV specialists were, are, and remain essential to caring for individuals diagnosed with HIV. But now, at least in the United States, as people are living longer with HIV, thank goodness, many still have their HIV infectious disease provider serve as their primary care provider. We see this gap because many infectious disease providers were not specifically trained on the nuances of menopause. It’s not necessarily part of their routine clinical assessment to ask about menopause. Concurrently, GYN menopause specialists likely were not trained on HIV and the state of the science on HIV today. So, there’s gaps with both clinicians.

Nanette Santoro, who is a menopause specialist, wrote an article that was published at the American College of Obstetrics and Gynecology, it’s at ACOG.org, where she highlighted the critical importance of providing evidence-based resources to women and how this is essential because there is a lot of misinformation and menopause has been monetized. Information is freely available on social media and many other media outlets, which is a wonderful thing, but not all of it is evidence-based. This can be very challenging. Information specific to women with HIV is limited, and menopausal resources can be limited. Clinicians, when providing this education or assessment to women living with HIV, it’s very important that they are pulling evidence, scientific evidence, and evidence from organizations like the Menopause Society, the International Menopause Society, so that they are receiving cutting-edge science, clinical guidelines, so that they can use this to provide the most relevant, up-to-date, evidence-driven information to people with HIV.

I feel very lucky to be a co-principal investigator of an NIH-funded, supported by the National Library of Medicine, a project called “Her & Now” with my colleague Dr. Sara Bares. Her & Now is an initiative that we are partnering with women living with HIV and expert HIV and expert menopause clinicians to develop a resource hub. It’s available at herandnow.org. We have videos, we have animated case presentations, we have a resource tab, and we are going to be launching our clinician-driven webinar series that’s going to start this September. I’m going to share resources that can be included as part of the posting of the podcast about our webinars and our registration. There’s going to be 6 of them. They’re about 90 minutes long, and they are going to be addressing distinct topics on midlife health and menopause for clinicians caring for any woman living with HIV at midlife. The women living with HIV have put together an incredible 9-minute video that is available on our website where they share their lived experience of being a woman living with HIV going through menopause, and there are other great resources too. To get back to my opening discussion in response to your question, it is essential to address it early on, provide that anticipatory guidance, and use resources that are evidence driven.

Eileen:
Well, thank you, and we will provide links to all those resources. But as we work through today, I think one thing I’d love for you to do now is give us some basic definitions of what menopause is, what perimenopause is, and what’s happening during those times?

Sara:
Yes, absolutely. I always start with a basic overview of pathophysiology, and I start with the ovaries. Although most know the ovaries for their diligent work with producing, storing, and releasing eggs or ova, many folks are unfamiliar with their second important job, and that’s producing hormones particularly estradiol or what’s known as E2. This is produced in the ovaries and specifically what are called the granulosa cells, and it is essential for regulating the menstrual cycle, breast development, neurologic system, the skeletal system, including the bone and the vascular system, and many other systems as well.

In all individuals born female, ovarian aging occurs across the lifespan. Females are born with millions of ova, and this number slowly declines and stops production at menopause. Menopause marks the end of ovarian function and is characterized by what is typical to be a dramatic or accelerated drop in estrogen levels. Menopause is often described in phases or stages, and each phase correlates with estrogen and another important hormone, which is called follicle-stimulating hormone or FSH, the degree of menstrual irregularity, and the last data point we look at is the timing of the final menstrual period.

In terms of stages of menopause, premenopause represents normal menses and hormonal regularity. The word perimenopause literally means around menopause and represents irregular menses, irregular periods, and often the beginning of symptoms like hot flashes for some women. During the perimenopause, we see dramatic fluctuations, so an increase in follicle-stimulating hormone and a drop in estradiol. This occurs while the body tries to essentially jumpstart a period in the presence of these very low hormone levels. This occurs particularly in the late perimenopause, where the most acute symptoms occur. Finally postmenopause occurs after 12 consecutive months of amenorrhea, no period, or greater, and this is occurring because there’s essentially a steady low-to-no estrogen in the female body.

Eileen:
Let’s talk a little bit about treatment. This is, as you mentioned, a natural process and also a little bit of the controversy around the use of hormones for women in midlife and at the menopausal transition. Can you take us through what is known about whether hormones are safe in general, what they are indicated for, and how we arrived where we are today?

Sara:
Yes, treatment with menopausal hormone therapy, a lot of folks used to refer to it as hormone replacement therapy, came about to help replace estrogen that’s lost during the menopause transition. Because as I mentioned, estradiol, the primary female sex hormone, is critical for maintaining bone health and helping with cardiovascular health.

Also, it’s been shown to help mood stability, because estrogen can play a role in binding to serotonin and serotonin uptake in the brain. We also know that estrogen may play a role in cognitive function, genito-urinary symptoms, etc. Naturally one would think that replacing estrogen that might be lost or declining during the perimenopause transition into the postmenopause would be the best treatment. That [is] a readily available treatment, menopausal hormone therapy, which is essentially a combination of estrogen and progesterone, which [is] another hormone that should be taken concurrently with estrogen when a woman has an intact uterus.

There was an amazing study, the Women’s Health Initiative, which is the largest and longest trial of postmenopausal women using menopausal hormone therapy. It has provided some remarkable and essential data to dictate guidelines for the care of women and women’s health. In July 2002, the first report from the Women’s Health Initiative or the WHI became available, and findings suggested that menopausal hormone therapy use may put women at increased risk for cardiovascular disease or coronary heart disease, venous thromboembolic embolism, or breast cancer.

If you do any reading on this from a social perspective, you’ll hear stories that essentially providers stopped prescribing menopausal hormone therapy for all women because of the risks that were incurred for this population. This happened again during that time in 2002, and we began to see a dramatic decline in prescribing these hormones, comfort with prescribing these hormones, and then use or requesting these hormones among women coming in who were transitioning or in that postmenopausal phase. However, subsequent analysis of these data have found that it really depends. These risks for breast cancer, coronary heart disease, or VTE [depend] on the type of menopausal hormone therapy being used, the dose, the duration of its use, the route of administration and whether a progestogen is needed. They’re needed [the progesterone component], as I mentioned, if a uterus is present. And it also is important to look back at the type of medications that were used during that study for hormone replacement. It was conjugated equine estrogen or CEE, a pill form, plus medroxyprogesterone acetate or MPA.

The analysis that was released in 2002 was among exclusively postmenopausal women that were between the ages of 50 and 79 years old with a mean age of about 63.2 years. When they did these subsequent analyses, they found that these risks depended upon the factors that I mentioned: the type, the timing, and the age. When they did other analyses they learned in the context of coronary heart disease, there was a greater risk for CHD [coronary heart disease] if menopausal hormone therapy was initiated further from menopause onset or greater than 10 years of onset in women who were aged older than 60 years.

Essentially, the WHI found that women between the ages of 50 and 59 years old in the estrogen arm had more favorable all-cause mortality and fewer MIs. If the use of MHT was initiated within 10 years of the onset of menopause, then it was associated with a lower CHD risk. That’s a really important thing to remember. The other thing that’s important to remember is that breast cancer is very individualized. So, it’s incredibly important to understand the woman’s risk for breast cancer, making sure you look at their family history, their own personal risk for the development of breast cancer, whether they’ve had it, whether they’re at risk, whether they’ve been treated in the past, and to make sure you take that factor into account when prescribing menopausal hormone therapy.

Again, it should always be prescribed in women under the age of 60 and within 10 years of the onset of menopause. Lastly, in the context of VTE, subsequent studies have suggested that there is a lower risk for VTE in women who are using transdermal formulations of estrogen patch or gel form compared to the pill form. These are all very important evidence-driven considerations. The menopause society website has incredible clinical guidelines and expert position statements on the use of menopausal hormone therapy that are very clear, easy to understand, and free to access, even for non-members. Remember that treatment is individualized and should not be administered in a cookie-cutter approach.

Eileen:
Perfect, I think it really is one of those examples where results of a study can be true, but the interpretation of them has to be done within the context of what was done, who was studied, and what the interventions were. It’s such a beautiful example of how we have to think about that in our care for patients. I’m going to have us return to our theoretical patient. As you recall, she’s 53, has been having nonspecific symptoms of sleep disturbance, irritability, maybe some memory difficulty. And on more detailed questioning, she does confirm that it’s the hot flashes that are contributing to her sleep disturbance. She’s also had some urinary frequency, some vaginal itching. She has not had a period for about 3 months. She had 4 periods over the 12 months prior, and she’s not been sexually active. I’ll also add some additional details: she does have a uterus, she has no personal or family history of breast cancer but is overdue for her mammogram. Her pap smears have been normal and she’s up to date on that. She’s never had a blood clot and has a distant history of smoking but stopped about 20 years ago. Two questions: How would you classify her? And would she be a candidate for a discussion about hormone replacement?

Sara:
Based on her history, she would be classified as being in the menopausal transition or perimenopause. It sounds like specifically the late menopausal transition. Key features supporting this classification [are] that she has had marked menstrual irregularity. She’s only had about 4 periods in the previous 12 months, and now 3 months, about 90 days, without a period.

Also, she’s experiencing classic symptoms associated with declining ovarian estrogen production, or menopausal transition, including hot flashes, which are also referred to as vasomotor symptoms, some sleep disturbance, urinary frequency, and vaginal itching, which may reflect genito-urinary syndrome of the menopause or GSM, and this is a result of estrogen deficiency. She is not yet considered postmenopausal, because menopause is defined retrospectively after 12 consecutive months of amenorrhea without any other obvious cause. In terms of classification, we know premenopause, she’s definitely not in that. Early perimenopausal transition, probably not, because she has some more advanced cycle irregularity. Late menopausal transition, which is the late perimenopause, yes, because this is characterized by intervals of amenorrhea, typically greater than or equal to 60 days and increasingly infrequent menses. She’s not postmenopausal , as we mentioned, because it’s only been 3 months since her last menstrual period. Based on this, I would say that she is in the late perimenopause or what we call the late menopausal transition phase.

I want to reiterate that menopausal hormone therapy is FDA approved for the use among women without HIV below the age of 60 or within 10 years of menopausal onset and healthy for vasomotor symptoms. These are the indications: vasomotor symptoms, genito-urinary symptoms, for the prevention of bone loss, and for women who may be experiencing premature hypoestrogenism. There are no official guidelines for the use of menopausal hormone therapy in women with HIV at this point, but we are pursuing a study on the use of menopausal hormone therapy in this population. The current [DHHS] HIV guidelines state that the use of menopausal hormone therapy in women living with HIV can be considered based on guidelines for women without HIV, and then specific individual characteristics in women living with HIV that are ascertained through a comprehensive health history.

One thing that stands out is she has not had a mammogram in the past year. So, I would definitely recommend that she has a mammogram. Then, based on other aspects of the health history that I know of from this case, doing a deeper dive and looking at oncology history, either personal or family history, I would begin a conversation about the use of hormone therapy in this patient, because she distinctly talks a little bit about her hot flashes that might be resulting in her sleep disturbance. That would be looking at [a] patch form of combined estrogen and progesterone therapy. Now, progesterone is always a pill. I would probably recommend an [estrogen] patch for her because she’s HIV positive, and we know that this group of women and patients in general have an increased risk for cardiometabolic comorbidities.

Also, I would highlight that she is experiencing some GSM or genito-urinary symptoms of menopause. I could also speak to her a little bit about the use of vaginal estrogen in the meantime while she might be deciding on the use of menopausal hormone therapy. Genito-urinary symptoms of menopause is clinically indicated for the use of menopausal hormone therapy at large, but vaginal estrogen has a very low systemic absorption rate. This could be started almost immediately with what I know in this patient and very little risk of developing any symptoms that might be commonly associated with menopausal hormone therapy at large.

Eileen:
Great. That really provides an awesome framework for how you could approach discussing therapy and weighing risks and benefits for this particular individual. You alluded to this, but there is a lack of evidence for MHT specifically in women living with HIV, and there is some effort underway to study that. Do you want to comment on the study that’s currently enrolling in the ACTG that is looking at menopausal hormone therapy?

Sara:
Yes, we are thrilled to share with you that we recently launched this past spring a study that is funded by the National Institute of Allergy and Infectious Diseases, Division of AIDS, also the ACTG, called “Menopausal Hormone Therapy in Women Living with HIV.” The acronym is HOT.

The principal investigators of this study are Dr. Michael Yin and Dr. Sara Bares, and I serve as the vice chair, and this is a multi-site study, the first of its kind, to prospectively evaluate the safety and efficacy of menopausal hormone therapy in a transdermal gel form in women living with HIV, with a primary aim to reduce vasomotor symptoms or hot flashes.

We have an incredible team of interprofessional and interdisciplinary specialists, you being one of them, Eileen, which is exciting. We have the opportunity in this trial to randomize 240 eligible participants to receive either transdermal gel form estradiol, with or without progesterone based on whether a female has a uterus or not, versus placebo with a number of visits over a 5-month period to look at hot flashes, different markers of microbiome, vaginal and anal, HIV-specific parameters, markers of cardiac inflammation, diabetes, physical function, mood, sexual function, neurocognitive cognitive assessment, a number of secondary and tertiary endpoints.

It’s ongoing recruitment right now at multiple sites nationally. We have 3 international sites. We’re hoping to garner rich data that demonstrates the use of this important intervention to help improve menopause symptoms and potentially related conditions and quality of life in women living with HIV.

Eileen:
Well, thanks for that overview. And just to summarize this rich discussion, I think there’s a couple of takeaways. First is for all of us as clinicians to discuss the symptoms of menopause and to recognize that these symptoms are not things that women need to be tough and get through but can have important health consequences and should be diagnosed as what they are and then potentially treated. From a treatment perspective, there’s been a dramatic shift in our understanding of the safety of menopausal hormone therapy, and there are great resources, which we will provide links to, in thinking about the risks/benefits for each individual and the treatment decisions should be individualized. Finally, there are some evidence gaps specifically around menopausal hormone therapy in women living with HIV, but there’s a lot of energy and excitement within the research field trying to address those questions. Hopefully, evidence will be coming in the next few years. If you’re a clinician listening to this and feeling slightly out of your depth, as I often do with new diabetes treatments, there are fantastic educational resources that have been developed recently to understand the patient experience side and the things you should be eliciting in your histories and also the potential for interventions.

Thank you for joining us, Dr. Looby. This was a really fantastic discussion.

Sara:
Thank you for having me.

Eileen:
And to our listeners, thank you for joining in to another episode of Viremic. Please send any comments or questions you have to viremicpodcast@JH.edu, and we’ll be back in 2 weeks to talk about all things HIV.

Announcer:
Viremic is sponsored by the Clinical Guidelines Program, a collaborative effort of the New York State Department of Health AIDS Institute and the Johns Hopkins University Division of Infectious Diseases.

Visit the program’s website at: HIVguidelines.org.

Viremic’s case discussions are for informational purposes only and not offered as medical or clinical practice advice for patients or clinicians. Any mention of specific medications or commercially available products is a description of use only, not an endorsement

The podcast is produced and edited by Mary Beth Hansen and Brian Hatcher with assistance from Jesse Ciekot and Laura LeBrun Hatcher.