Women with hepatitis B and/or C come from all social, educational, cultural, religious and economic backgrounds. The emotional and physical effects of hepatitis vary greatly from one woman to another and can be different to men. Some women may feel forgetful or vague; others may feel tired and depressed or short-tempered. Lifestyle choices are important in managing the effects of hepatitis.
Sex and hepatitis C
Risk of transmission during sex is generally very low. Menstruation, spotting or the presence of sexually transmitted infections, cuts, blisters or abrasions all increase the risk of sexual transmission of hepatitis C. Some forms of sex including abrasive or dry sex, sex toys, anal sex and rough or traumatic sex may cause cuts and abrasions (possibly not noticeable at the time), which may increase the risk of transmission through blood to blood contact. Under these circumstances it is advisable to use safer sex practices (condom, water-based lubricant, dams and/or gloves) to reduce the risk of transmission. Sex practices that involve the sharing of sex toys or other equipment may need to be revised to reduce the risk of transmission of hepatitis C, hepatitis B, and HIV and other sexually transmissible infections.
There is no evidence to indicate that women with hepatitis C may experience a decreased sex drive. Tiredness and depression however, may mean that there is little energy for sex. It is important to have open and honest communication between partners which may assist in increased understanding of individual needs. Reports indicate that hepatitis C treatment may reduce a person’s sex drive, however some people experience an increased sex drive while undertaking treatment, possibly due to a reduction in hepatitis C related fatigue.
Some women living with hepatitis C may find it difficult to tolerate the oral contraceptive pill if the liver’s ability to break down substances in the pill is impaired. Women experiencing significant symptoms of hepatitis C should discuss their contraceptive options with a trusted and understanding doctor and take advice on oral and other forms of contraception available to them.
Hepatitis C does not affect fertility, and does not increase the risk of liver disease in women who have hepatitis C. The risk of transmission of the virus from mother to child is very low at around six percent or less during birth. Women with an undetectable viral level (PCR negative) are highly unlikely to pass the virus to their babies. Co-infection with HIV increases the risk of hepatitis C transmission from mother to child unless the mother is on HIV treatment.
It is important that women are aware that having hepatitis C does not mean they can’t have a natural vaginal delivery. Hepatitis C is not, in itself, a medical condition requiring a caesarean delivery. A study published in Hepatology in 2000 found that “genotype, viral load, vaginal vs. caesarean delivery, breast feeding or HIV co-infection were not associated with transmission”.
Babies born to women with hepatitis C will have antibodies to the virus. Antibodies are the proteins produced by the body to help fight off infections. These are passed through the mother’s placenta to the baby during pregnancy. They have no harmful effect on the baby and after about 18 months, most babies will have naturally cleared their mothers’ antibodies.
It is imperative that women, and their partners’, undertaking combination therapy (pegylated interferon and ribavirin) use two reliable forms of contraception to ensure they do not become pregnant during the treatment, and for six months following treatment. Both interferon (pegylated and non-pegylated) and in particular, ribavirin have been shown in animal studies to cause birth defects.
Traces of the hepatitis C virus have been found in some breast milk and colostrum (produced by the mother in the first few days after the birth and prior to the production of breast milk), but in insufficient amounts to transmit hepatitis C. As no cases of hepatitis C transmission have been documented via breastfeeding and breast milk protects the baby from illnesses, especially in the first weeks of life, as well as providing a balanced food supply, it is currently recommended that breastfeeding be encouraged. The final decision is of course, up to the mother.
Mothers with hepatitis C need to maintain good breast health while feeding their infant. Breast damage such as cracked nipples could create a possible risk of transmission as blood in the breast milk could enter through small tears or scratches in or around the baby’s mouth. If a mother has cracked nipples and wants to continue to breastfeed her baby it is recommended that she seeks specialist advice.
Globally, the most common means of acquisition of hepatitis C for children is from their mothers (vertical transmission), from receipt of blood or blood products, and through mass vaccination programs with non-sterile equipment. Since February 1990 when screening for hepatitis C in Australia began, most transmission of the virus to children has been vertical transmission before or during birth. It is estimated that between one and two per cent of women of child-bearing age in Australia are hepatitis C positive and the transmission rate from mother to child is about five percent or less. Based on these figures, we would expect to see relatively few new cases of infant hepatitis C each year. However children rarely show symptoms of acute (early) hepatitis C infection, and unless the mother is known to have hepatitis C, they may go undiagnosed.
Antibody testing of infants is not recommended until about eighteen months of age as it can take this period of time to completely clear the mothers’ antibodies from their body. Most chronically (long-term) infected children show no symptoms, although some may have non-specific fatigue and/or abdominal pain. The majority of children remain clinically well for two or more decades if there are no other risk factors for liver disease, although there have been some cases of hepatitis C induced liver disease and liver failure reported. In the first few years a child may have raised liver enzyme levels which then become normal.
Some European research indicates that approximately twenty percent of children may clear the virus, fifty percent will have chronic asymptomatic (without symptoms) infection and thirty percent will have evidence of chronic active infection. There have been very few studies of interferon treatment in children and it is not approved for hepatitis C treatment in children in Australia.
Children identified as having hepatitis C should be vaccinated against both hepatitis A and hepatitis B. The complication of having hepatitis A in addition to hepatitis C increases the risk of what is known as fulminant hepatitis and death in children. Co-infection with hepatitis C and hepatitis B is associated with higher rates of cirrhosis and liver cancer. For these reasons, vaccination is very strongly recommended.
Most women experience no changes in menstruation because of their hepatitis C. However, women experiencing significant symptoms from hepatitis C may also experience irregularities in their menstrual pattern, including shorter or missed periods. Changes in menstruation may occur for a number of reasons and should be discussed with a doctor as they may not be related to hepatitis C.
Hepatitis C virus is transmitted through blood to blood contact. As menstrual fluids contain blood as well as other bodily fluids they are potentially a means of hepatitis C transmission. To date there is no evidence of transmission occurring in this way in Australia. Nevertheless it is sensible to take steps to reduce any risk of transmission through menstrual fluids. It is recommended that safer sex practices be followed during menstruation (condoms, dams, gloves and water-based lubricant), particularly if a sexual partner has any open cuts, wounds or abrasions.
The risk of hepatitis C transmission from used sanitary items will be reduced if the items are placed in leak-proof plastic bags in general rubbish or disposed of in hygienic disposal units. Hands should always be washed after handling blood-stained items. Clothing that is blood-stained should be soaked in cold tap water then washed in the usual manner in cold water.
Hepatitis C may aggravate the hormonal changes experienced by women as part of menopause. Additionally oral contraceptives and/or hormone replacement therapy (HRT) may not be well tolerated by some women with hepatitis C. It is recommended that any woman experiencing problems with menopause and/or HRT seek the advice of a trusted doctor.