Does lipo affect women in a different way from men? Susan Cole investigates
Lipodystrophy (body fat changes) in people living with HIV is a well documented
phenomenon. We know it’s a syndrome characterised by redistribution
of body fat, leading to fat decreases in some parts of the body, usually the
face and limbs, and fat increases in others, usually the trunk.
Lipo can include increased fat in the blood, resulting in abnormally high
cholesterol and triglyceride values, which may in turn my lead to heart disease.
We now know it’s caused primarily by HIV medications, particularly certain
nucleoside analogues and protease inhibitors, and even perhaps by HIV itself
(see Treatment News, page 32). However debate rages over whether it affects
women differently to men.
Most studies that have examined lipodystrophy have primarily included men
living with HIV, with few looking at the syndrome in women. A study published
in the December 2003 edition of the Journal of Acquired Immune Deficiency
Syndromes compared lipodystrophy in men and women. Fat loss from the face,
arms and legs, together with the development of fatty deposits elsewhere in
the body, are common signs of lipodystrophy in men. But these researchers
found women with HIV were more likely to experience overall body fat loss,
rather than peripheral fat loss combined with central fat gain in the chest,
abdomen and upper back.
But other studies suggest women do accumulate fat in their breasts and stomach.
US lipo expert Dr Donald Kotler thinks women are more likely to experience
fat gain in their stomach and breasts, whereas men are more likely to experience
fat loss from their face and limbs. However many men and women experience
both.
It is unclear why there may be differences in the manifestations of lipodystrophy
in men and women. Men are more likely to have less fat on their faces and
limbs prior to the onset of lipodystrophy, which may explain why they are
more likely to report changes in these areas. Perhaps men living with HIV
may also burn fat faster than women. Different hormonal influences could contribute
to the differences.
Another study compared fat levels in women living with HIV on HAART, with
women not on medication and with women who were HIV negative. It was found
that women on HAART had less fat in their legs than either of the other groups.
Mary*, 39, is on d4T, 3TC and nevirapine
“I’ve noticed recently that my legs are becoming increasingly skinny and my boobs are getting bigger. My stomach also seems to be getting larger. What’s most upsetting is that I seem to be losing a lot of weight from my bum - I used to be really proud of it before. I’m worried people are going to realise that I’m HIV positive because of these changes. What’s the point of taking medication that’s meant to make you better, if you just end up looking sicker than you did before? I felt like just stopping taking my pills, but a friend has suggested that I speak to my doctor about changing my medication. I don’t think that it will make things better, but I hope at least it will stop things from getting any worse.”
Paula*, 42, diagnosed HIV positive in 1992
“I was taking the protease inhibitor indinavir. After a few months I
began to notice my body was changing. My breasts were starting to get larger
and my arms and legs were becoming thinner. At the time I didn’t think
that it could have anything to do with my medication, I assumed it was HIV
itself that was causing these changes”.
Paula* combated lipodystrophy with lifestyle changes. “I started to
learn about how the food I ate affected my metabolism and the importance of
good nutrition.
“I reduced the amount of saturated fats I ate and began to eat more
fresh fruit and vegetables. I began a regular workout routine, including weight
training and running. I managed to change the shape of my body and feel so
much healthier.”
Dr John Wright, senior registrar at the Nkosi Johnson Unit, Charing Cross
Hospital, London, has seen female patients with lipo but he suspects the effect
may be less pronounced than in men.
“I’ve recently switched three of my female patients who were on
d4T for about three years to another combination, usually tenofovir or abacavir
and an NNRTI,” said Dr Wright. “They’d experienced some thinning of the face and legs, with their
breasts getting larger. I’ve also seen some women who have lost weight
from their bottoms, which is particularly distressing for my African patients.
“I haven’t seen any fat accumulation on the back of the neck and
back of any female patients, which I see in males.
In my experience lipodystrophy hasn’t seemed as pronounced in women
as in men. I’ve sent men for New Fill because of fat loss in their faces,
but I haven’t sent any women”.
So what can a woman living with HIV do if she experiences lipodystrophy or
is worried she may get it? One option is to switch treatment, particularly
if you are on d4T, to an alternative nucleoside/nucleotide, like abacavir
or tenofovir.
Diet and exercise, as well as stopping smoking, can make a difference in fighting
lipodystrophy. A diet low in saturated and high in unsaturated fats, along
with regular exercise can significantly reduce the risk of getting a heart
attack and decrease both body fat and the levels of fat in the blood.
Surgical interventions can reduce the effects of lipodystrophy. Liposuction,
a cosmetic surgery procedure, can remove fat from the back of the neck and
around the breasts. It cannot be used for abdominal fat because with lipodystrophy
fat forms around organs rather than under the skin. Cosmetic face fillers
like New Fill can be used to combat fat loss in the face and are available
on the NHS in some clinics in London as well as in Manchester, Portsmouth,
Brighton and Birmingham.
Other pharmaceutical interventions may be useful in combating the effects
of lipodystrophy. Two classes of drugs can be used to lower blood fats: statins
(like atorvastatin) and fibrates (such as gemfibrozil). Metformin can be used
to treat insulin resistance. Human growth hormone may be used to treat body
composition changes. Somatropin can help increase lean body mass, which is
why it has been used to treat both HIV-associated wasting and lipodystrophy,
though it is extremely expensive and currently unavailable on the NHS and
may be better at reducing central fat gain than reducing breast size.
Paula certainly feels much better about herself since she started combating
the effects of lipodystrophy. “When I started to get lipodystrophy it
had a profound psychological impact on me. My self-esteem was rock bottom
and I felt that that no one could ever find me attractive again. Changing
my diet and having a regular exercise routine made me feel more in control
of my life and I started to see positive changes in my body.”
Sandra* 36, is worried about developing lipo
“I was on Combivir (AZT and 3TC) and efavirenz for two years when I
heard that AZT could cause lipodystrophy. I’m more scared of getting
lipodystrophy than any other side effect from my medication - my appearance
is more important to me than anything else. I was a little worried about approaching
my doctor about switching my combination, particularly as I hadn’t got
lipodystrophy. I needn’t have worried - my doctor was fine about it.
We discussed various options and we agreed that I should switch to FTC, tenofovir
and efavirenz. I’ve been on my new combination for a few months now
and haven’t experienced any side effects”.
* Names have been changed.
