DECLARATION OF CONFLICT OF INTEREST

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1 DECLARATION OF CONFLICT OF INTEREST DISCLOSURE INFORMATION: Sexual Dysfunction in Men and Women with Heart Disease: What Do We Know? Elaine E. Steinke, PhD, RN The following relationships exist related to this presentation: None

2 Sexual Dysfunction in Men and Women with Heart Disease: What Do We Know? Elaine E. Steinke, RN, PhD, FAHA Professor, School of Nursing Wichita State University, Wichita, KS, USA Contact Info:

3 Sexual Dysfunction and CVD Vascular Mechanisms Types of sexual dysfunction Contributing Factors Specific cardiac conditions Sexual function Sexual dysfunction Conclusions

4 Proposed Vascular Mechanisms of Sexual Function Erectile function neurovascular response to arousal Vasodilatation of penile or clitoral arteries, relaxation of trabecular muscle Engorgement of sinusoids dynamic venous obstruction Clitoral engorgement thought to be similar in mechanism to penile erection NO from endothelial cells and neural tissue smooth muscle relaxation Regulation of blood flow and clitoral erectile function - same nitric oxide-cyclic guanosine monophosphate (cgmp) cgmp activates a protein kinase blocks calcium influx smooth muscle relaxation, vasodilation, increased blood flow, erection Sub-cellular pathways help regulate cgmp levels PDE5 Kaya et al. Int J Impotence Res, 2007;19:326-29; Archer et al. Drugs Aging, 2005; 22,823-44; Solomon & Jackson. Sex Relation Therapy, 2003; 18:

5 Organic vs. Psychogenic Sexual Dysfunction Organic biologic findings without significant emotional or mental distress Psychogenic No biologic findings Mixed Features of both types Characteristic Organic Psychogenic Onset/Timing Gradual (unless trauma or surgery) Acute Symptom course Progressive Intermittent, selective Organic risk factors Present Absent or variable Partner problem Secondary At onset Presence of anxiety Secondary Primary Adapted from: Hatzichristou et al. 2010, J Sex Med; 7: (Table 3 & 4)

6 Male Sexual Dysfunction Over 80% of ED due to organic causes Vascular disease most common Linked with CVD risk factors across populations HTN Heart disease Diabetes, elevated glucose levels Hypercholesterolemia Mechanisms endothelial cell dysfunction, reduced nitric oxide, minimal conversion to cgmp, elevated intracellular calcium, corpora cavernosal SMC contracted no vasodilation or erection Solomon & Jackson. Sex Relation Therapy, 2003; 18: ; Hackett. Internat J Clin Pract, 2009; 8:

7 Male Sexual Dysfunction Saudi study (N=1,464) clinical diagnosis of sexual dysfunction 93% ED 51% premature ejaculation 8% low sexual desire 20% psychogenic vs. 80% organic cause of ED 41% had moderate, 49% severe ED Elderly men - ED more prevalent in those with CAD % vs. 72.7% general population Less sexually active El-Sakka. J Sex Med 2007; 4: ; Justo et al. Internat J Impot Res, 2010; 22:40-44

8 Definitions of Women s Sexual Dysfunction Disorder Women s sexual interest/desire disorder Subjective sexual desire disorder Genital sexual arousal disorder Women s orgasmic disorder Vaginismus Dyspareunia Definition Absent/diminished feelings of interest/desire, absent sexual thoughts/fantasies; beyond normal lessening w/ lifecycle or duration of relationship Absence of markedly diminished feelings of sexual arousal (sexual excitement/pleasure) from any sexual stimulation Absent or impaired genital sexual arousal (vulval swelling/lubrication) from any sexual stimulation Lack of orgasm, marked decline in intensity of sensations, or marked delay in orgasm Persistent difficulties w/ vaginal entry of penis/object; anticipation/fear response; involuntary pelvic muscle contraction Persistent/recurrent vaginal pain w/ attempted or complete vaginal entry The woman s experience of sexual arousal is not primarily focused on genital vasocongestion, lubrication, perception of swelling Emotions and cognitions strongly modulate women s subjective sexual arousal Basson et al. J Sexual Med, 2004; 1(1),40-48

9 Prevalence of Female Sexual Dysfunction General Population FSD Analysis of 11 studies Average Across Studies Range Problem w/ desire 64% 16-75% Orgasmic difficulty 35% 16-48% Arousal difficulty 31% 12-64% Sexual pain 26% 7-58% 62-89% persisted for several months 25-28% persisted for 6 months Hayes et al. J Sex Med, 2006; 3,

10 Factors Related to FSD & CVD Atherosclerosis of arterial bed supplying female pelvic anatomy Decreased vaginal engorgement and clitoral erectile insufficiency syndromes Organic causes Neuropathy or vascular disease Clitoral cavernosal ischemia fibrosis & loss of smooth muscle in clitoral cavernosal tissue Effect of CVD risk factors HTN, smoking, diabetes, hyperlipidemia Archer et al. Drugs Aging, 2005; 22,823-44

11 Factors Related to FSD & CVD Age following menopause Decline in estrogen Estrogen may vasodilation, engorgement by NO production or activating K+ channels Clitoral or labial engorgement, vaginal lubrication Post-menopausal women ERT improves sexual function orgasm, lubrication, pain Does not seem to affect libido Caution due to risk of thrombotic CV events Psychological causes FSD occurs in CVD without significant disability Fear of recurrent MI/stroke Depression significant factor in diabetic women Archer et al. Drugs Aging, 2005; 22,823-44

12 FSD and CAD Female sexual dysfunction has been physically disconcerting, emotionally distressing, and socially disruptive. (p. 326) 20 women w/ CAD, 15 matched healthy women Sexual intercourse episodes per month Diagnosis of female sexual dysfunction CAD women Healthy Women P-value p<0.05 n=12 (60%) n=5 (33%) CAD women desire, arousal, lubrication, orgasm, pain all significantly lower Kaya et al. Int J Impotence Res, 2007;19:326-29

13 Sexual Problems in CVD by Age & Gender Problem Reduced sexual desire Problems w/ orgasm Pain during intercourse Premature ejaculation Age <40 yrs (Men n=3, Women n=10) Women 50% Men 0% Women 10% Men 33% Women 10% Men 33% Ages yrs (Men n=33, Women=15) Women 53% Men 21% Women 20% Men 6% Women 13% Men 3% 50+ yrs (Men n=75, Women n=17) Women 65% Men 28% Women 12% Men 7% Women 12% Men 1% Men 10% Men 25% Men 12% Late ejaculation Men 0% Men 0% Men 1% Erectile dysfunction Men 33% Men - 64% Men 63% Vaginal dryness Women 30% Women 20% Women 29% Traeen & Olsen. Sex Relation Therapy, 2007; 22:

14 Sexual Dysfunction in Heart Failure Sample of 76 men, 24 women Women Men FSD or ED 87% 84% Reduced desire 87% 76% Orgasmic Problems 62% 73% Dissatisfaction 83% 80% Decreased vaginal lubrication Decreased lubrication + pain Unsuccessful or interrupted intercourse 80% 50% 76% Schwarz et al. Internat J Impot Res, 2008; 20,85-91

15 Sexual Dysfunction in HF Study of 75 men and 22 women w/ HF Decreased odds of being sexually active: Tobacco use (p=.001) Alcohol use (p=.016) Diabetes (p=.023) Number of medications (p=.012) These variables accounted for 33% (R 2 =.33) of the variance in sexual activity. No difference in sexual activity by class of medication Steinke et al. Dimens Crit Care Nurs, 2009; 28:

16 Sexual Activity and CAD Women Study of 35 women with either NSTEMI or unstable angina Importance of sexual activity Highly Mostly Somewhat Mostly unimportant Not important at all 34.3% 25.7% 20% 11.4% 8.6% 49% had resumed sexual activity 35% not satisfied, 41% mostly dissatisfied, 24% somewhat dissatisfied with sexual relations For those not resuming sexual activity Less desire, much lower than prior to illness 83% Depression 67% Patient/partner fear of MI 72% Eyada & Atwa. J Sex Med. 2007; 4:

17 Sexual Activity/Function of Women with CAD Self-report measures from the US Medical Outcomes Study in the Heart & Estrogen/Progestin Replacement Study (HERS) 2,736 post-menopausal women with CAD and intact uteri Correlates of sexual activity and dysfunction 39% sexually active 65% reported at least 1 sexual problem Lack of interest, inability to relax, difficulty in orgasm or arousal, discomfort with sex Factors associated with sexual activity younger age, fewer years since menopause, married, better self-reported health, higher parity, moderate alcohol use, non-smoking, no chest discomfort, no depression Lower sexual problem scores associated with: Unmarried, better educated, better self-reported health, higher BMI Addis et al. Obstet Gynecol, 2005; 106,

18 Sexual Satisfaction & Frequency of Sex by Gender Study of 462 men, 51 women post-mi Women Men Before MI After MI Before MI After MI Satisfaction* 3.24 (1.24) 2.90 (1.39) 3.68 (1.03) 3.47 (1.12) Frequency (1.58) 2.90 (1.88) 4.37 (1.31) 3.78 (1.66) *ranged from not at all (1) to a great extent (5) satisfied + ranged from none (0) to 3 times per week (6) M(SD) Women reported less satisfaction and sexual frequency than men Frequency and satisfaction declined for both Age negatively and education and perceived health positively associated with frequency and satisfaction Drory et al. Am J Cardiol, 2000; 85,

19 Sexual Satisfaction & Sexual Activity Study of 276 Israeli men, aged yrs, post-mi 1 35% reported reduction in sexual satisfaction Sexual satisfaction prior to MI had highest contribution to satisfaction post-mi (0.40, p<.001) Age inversely correlated with satisfaction (-0.19,p<.001) 88% resumed sexual activity post-mi 50% within 1 month 35% reported reduced frequency Diabetes, perceived health prior to MI, depression were correlated both with sexual activity and satisfaction Heart Failure 2-4 Decline or loss of satisfaction in about 1/3 of HF patients Similar patterns for partners 1. Drory et al. Cardiol 1998; 90: ; 2. Jaarsma. Europ J Cardiovasc Nurs. 2002;1: Jaarsma et al. Heart Lung. 1996;25: Westlake et al. J Heart Lung Transpl. 1999;18:

20 Sexual Satisfaction - Coronary Intervention Purpose : To elicit sexual satisfaction of patients before and after treatment interventions (CABG, PTCA) N=280 patients with CAD followed for 8-years 60% satisfied before intervention, 63% at 8-years Reported sexual satisfaction by group: CABG PTCA Medication Before intervention 57% 56% 73% 8-years 62% 64% 62% Women more satisfied, but declined over time (pre to 8-yrs) Women: 77% to 70% Men: 52% to 59% Lukkarinen & Lukkarinen. Heart Lung, 2007; 36:

21 Sexual Satisfaction and Anxiety Role of sexual satisfaction in reducing anxiety post-mi Compared low anxiety to high anxiety groups Anxiety Score High Anxiety Low Anxiety Significance (SD 6.91) Sexual Satisfaction (SD 2.22) (SD 3.78) P< (SD 1.64) P<.001 Current smoker 33.3% 12.5% P<.05 No risk factors 21.2% 43.8% P<.01 Those with higher anxiety had greater percent of risk factors (81.8% vs. 56.2%) that might influence sexual function (p<.01) Low anxiety group were older age 55 (71.8% vs. 24.2%, p<.001) Older age, coronary risk factors, and sexual satisfaction had independent effect on anxiety, 42% of variance at 5 months post-mi Steinke & Wright. Europ J Cardiovasc Nurs, 2005; 5:

22 Sexual Anxiety, Satisfaction, & Self- Efficacy HF & Healthy Elders Sexually active and non-active in the last 2 months Not sexually active Lower sexual self-concept (p<.001), sexual self-efficacy (p<.001), sexual satisfaction (p<.001) Less sexual anxiety (p<.01) No difference in sexual depression scores Logistic regression factors contributing to sexual activity Increased sexual self-concept 1.78 greater odds sexual activity Sexual anxiety & sexual self-efficacy independent effect on sexual activity (p<.01) and greater odds of sexual activity 2.48 for sexual anxiety, 1.87 for sexual self-efficacy Steinke et al. Heart & Lung, 2008; 37,

23 Hypertension & Sexual Dysfunction HTN may cause endothelial dysfunction by shear stress in vessel wall; oxidative stress, endothelial cell injury Erectile problems Arteries, arterioles, sinusoids of corpus cavernosum dilation impaired Non-endothelium dependent dilation?? e.g. damage to SM cells Vulvar vaginal congestion, problems with lubrication and sexual satisfaction Diminished genital blood flow may result in clitoral and vascular insufficiency vasculogenic FSD Change in blood flow affects clitoral smooth muscle and vaginal wall impaired response to sexual stimulation Antihypertensive drugs may worsen symptoms Beta blockers, thiazide diuretics Consider substituting drug, e.g. loop diuretic, ARB PDE5 inhibitors may help ED in men Clayton & Ramamurthy. Adv Psychosom Med 2008; 29:70-88; Kloner. Internat J Impot Res 2007; 19: ; Doumas et al. J Hypertens, 2006; 24, ; Archer et al. Drugs Aging, 2005; 22,823-44

24 Hypertension & FSD Study of 216 women w/arterial HTN and 201 normotensive women FSD in 42.1% of those w/ HTN vs.19.4% in normotensive SBP levels significantly related to Female Sexual Function Index (r=-0.67, p<.001) BP control related to lower prevalence of FSD Significant predictors of FSD Increasing age, increasing SBP, β blocker therapy Doumas et al. J Hypertens, 2006; 24,

25 Hypertension & FSD Survey of 67 women, mean age=60.4 yrs 81.3% had sexual partner 42.6% had sexual problems Mean duration 3.9±1.2 yrs Sexual problems included: Anxiety/inhibition w/ sexual activity 48.7% Bleeding/irritation w/sexual activity 30% Lack of pleasure w/sexual activity 61.8% Over 50% did not regularly engage in sexual activities Burchardt et al. J Sex Marital Ther, 2002; 28,17-26

26 Interventions Sexual Therapy Assessed impact of sexual therapy on time to resumption of sexual activity, quality of sexual activity, levels of anxiety, marital satisfaction in male cardiac pts (MI, CABG) participating in a CR program. Patients aged 70, admitted to outpatient CR Randomized to sexual treatment/counseling (n=47) or control (n=45) Pre-cardiac event: all had satisfactory sexual function, few sexual problems, high desire Treatment group: Higher return to sexual activity (87% vs. 50% control) Klein et al.. Europ J Cardiovasc Prev Rehabil 2007; 14:

27 Sexual Therapy Treatment group: Greatest change in Confidence in maintaining erection (p<.01) Satisfaction in quality of sexual relations with partner (p <.05) Frequency of erection (p<.05) Sexual pleasure (p<.05) Level of sexual desire (p<.05) 6-weeks post-event, 1/3 had not returned to sexual activity Most had returned in ~1 month post-event ½ of untreated group returned in this time Intervention shortened time to return to sexual activity Recommend guidance and support through return to sexual activity Klein et al. Europ J Cardiovasc Prev Rehabil. 2007; 14:

28 A Social-Cognitive Sexual Counseling Intervention Pilot study 10 MI patients, 3 partners Aim: to test the effects of sexual counseling intervention on sexual satisfaction, self-efficacy, anxiety, depression; QOL, knowledge, return to sexual activity in those ages 45 and older Intervention 15 min. video on return to sexual activity, home setting 3 mailed, timed newsletters (2, 4, 6 weeks) Telephone assessment & counseling (4 & 6 weeks) Steinke, E.E., et al., A social-cognitive sexual counseling intervention after myocardial infarction. 2010; Wichita State University: Wichita, Kansas, USA

29 A Social-Cognitive Sexual Counseling Intervention - Findings QOL all scores lower than US nat l mean and at or below 25 th percentile for recent MI Physical, Role-Physical functioning affected at 8 weeks Affecting Social Functioning and Mental Health Role Emotional and Mental Health lower Sexual Self-concept Patients: Not sexually anxious or depressed, moderate sexual self-efficacy, but lower sexual satisfaction Partners: More sexual anxiety & depression, lower sexual satisfaction MI patients somewhat knowledgeable Decline in sexual activity, Pre- 80%, 8-weeks 60% Mean time to return 3.38 weeks, range 1 to 8 weeks More general activities at 8 weeks, e.g. hugging, kissing, fondling Telephone assessment problems with sexual desire, symptoms

30 Conclusions Routine assessment of sexual dysfunction, sexual counseling, and management with cardiac patients Cardiac patients may not speak up about sexual issues May not feel the need to ask about future sexual activity Be aware of biases women, older adults, sexual orientation Evaluation of co-morbid conditions, organic problems as well as anxiety and depression More study of sexual dysfunction is needed, particularly for women, including: Consistent measures of sexual dysfunction Accurate prevalence estimates of sexual dysfunction in CVD and chronic disease RCTs in patients with CVD, MI, HTN, HF Evaluation of medication therapies for FSD in CVD

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