Effects of Sexual Function of Essential Hypertensions in Women

Association between cardiovascular disease and risk of female sexual dysfunction: a systematic review and meta-analysis

AIMS

Female sexual dysfunction (FSD) is a considerably underestimated condition. It has been repeatedly reported that patients with cardiovascular diseases (CVD) may suffer from an increased risk of FSD. However, there is still a lack of comprehensive and systematic evaluation of various CVD and FSD. We aimed to elucidate the association between CVD and FSD through a comprehensive literature review and meta-analysis.

METHODS AND RESULTS

The PubMed, Scopus, Embase, and Cochrane Library databases were systematically searched from inception to 28 February 2023. We identified all relevant studies reporting the risk of FSD in subjects with or without CVD. The associations between CVD and the risk of FSD were assessed by calculating pooled odds ratios (ORs) (cross-sectional studies) and risk ratios (RRs) (longitudinal studies) with 95% CIs. We employed random-effects models to account for potential heterogeneity, and the quality of the included studies was assessed using the Newcastle-Ottawa Scale. Fifty-four articles with 148 946 individuals were included in our meta-analysis. Compared with control subjects, subjects with CVD had a 1.51-fold increased risk of FSD (OR 1.51 95% CI, 1.34-1.69, P < 0.001, heterogeneity I2 = 91.4%, P < 0.001). Subgroup analyses indicated that the association between CVD and FSD remained significant in longitudinal studies (RR 1.50 95% CI, 1.21-1.86, P < 0.001, heterogeneity I2 = 86.7%, P < 0.001). Particularly, hypertension (OR 1.41 95% CI, 1.23-1.62, P < 0.001, heterogeneity I2 = 82.7%, P < 0.001), stroke (OR 1.81 95% CI, 1.54-2.12, P < 0.001, heterogeneity I2 = 0%, P < 0.423), and myocardial infarction (OR 2.07 95% CI, 1.60-2.67, P < 0.001 heterogeneity I2 = 82.4%, P < 0.001) were significantly associated with FSD. Meta-regression revealed that the primary sources of heterogeneity in FSD are attributable to adjustments for covariates, study design, and study population.

CONCLUSION

Our meta-analysis indicated that patients with CVD suffer from a greater risk of developing FSD. Meanwhile, we validated these findings in longitudinal queues. Notably, conditions such as hypertension, stroke, and myocardial infarction demonstrated a significant association with the incidence of FSD.

Global prevalence of sexual dysfunction among women with metabolic syndrome: a systematic review and meta-analysis

Background

Sexual dysfunction is a common disorder among women, especially during menopause. Metabolic syndrome is a multifactorial disease that, according to previous studies, there is a relationship between the metabolic syndrome and sexual dysfunction among women. The aim of this systematic review and meta-analysis is to obtain the prevalence of Female Sexual Dysfunction (FSD) among women with metabolic syndrome, and to analyze available related evidence.

Methods

In this systematic review and meta-analysis, the keywords of MeSH, female sexual dysfunction, FSD, metabolic syndrome were searched in PubMed, Web of Science, Scopus, Science Direct and Google Scholar. The searches were conducted without a lower time limit and until May 2022.

Results

The prevalence of FSD among women with metabolic syndrome was found to be 39.3% (95% CI: 28.3-51.5). In the subgroup analysis and in the review of 4 studies, the prevalence of sexual dysfunction in postmenopausal women with metabolic syndrome was 49.8% (95% CI: 26.1-73.6). Analyzing the results of the meta-regression test in examining the effect of the three factors of sample size, year of the study, age, and BMI of the patients on the heterogeneity of the meta-analysis, showed that with the increase of the sample size, the prevalence of sexual dysfunction among women with metabolic syndrome decreases (p < 0.05). Moreover, the prevalence of sexual dysfunction among women with metabolic syndrome increases (p < 0.05) with the increase in the years of conducting studies and the mean of age of women with metabolic syndrome. Also, with increasing mean of BMI of female patients with metabolic syndrome, the prevalence of sexual dysfunction in these women also increases (p < 0.05).

Conclusion

Female sexual dysfunction is a global health problem that can affect women's life to a great extent. Metabolic syndrome, which is a set of factors such as obesity, high blood pressure, and diabetes, affects sexual dysfunction in women. From this study, it can be concluded that there is a close relationship between metabolic syndrome and female sexual dysfunction.

Sacubitril/Valsartan Improves Sexual Function and Fibrosis of the Clitoral and Vaginal Tissues in Female Spontaneously Hypertensive Rats

ABSTRACT

Female sexual dysfunction is common in hypertension. The effects of sacubitril/valsartan (SAC/VAL) as a potential therapy for hypertension and heart failure have not been studied in relation to sexual function and genital fibrosis in female spontaneously hypertensive rats (SHRs). Thirty female SHRs were administered VAL, SAC/VAL, or saline. Ten normotensive female Wistar-Kyoto (WKY) rats were included in the control group. We assessed estrous cyclicity and sexual behavior in the female rats. In addition, the morphology of clitoral and vaginal tissues was evaluated by histological analyses. Western blotting and enzyme-linked immunosorbent assays were used to assess the levels of fibrotic markers in vaginal and clitoral tissues. Furthermore, the protein levels of phosphatase and tensin homolog deleted from chromosome 10 (PTEN), phosphoinositide-3-kinase (PI3K), and AKT expression were measured by Western blotting. SAC/VAL treatment improved hypertension-induced sexual dysfunction, exhibited as a prolonged estrus phase, increased receptivity and proceptive events, and decreased aggressive events, compared with those of VAL treatment and control SHRs without treatments. In addition, SAC/VAL-treated SHRs had lower levels of fibrotic markers, estradiol, and estrogen receptor α/β than the levels of VAL-treated SHRs or SHRs without treatment. Moreover, SAC/VAL decreased p-PTEN expression and increased p-PI3K and p-AKT expression at the protein level compared with those in VAL treatment alone. VAL and SAC/VAL treatments have significantly increased sexual receptivity and proceptivity, decreased aggressiveness, and improved the fibrosis of vaginal and clitoral tissues in female SHRs. However, SAC/VAL treatment shows more effective results compared with VAL treatment, which may be related to the PTEN/PI3K/AKT pathway.

Management of Hypertension with Female Sexual Dysfunction

Female sexual dysfunction (FSD) in hypertension has been less studied than male sexual dysfunction, and antihypertensive agents’ impact on female sexual function is not defined. In this review, randomized double-blind clinical trials and cross-sectional studies related to female sexual function in hypertension were analyzed from 1991 to 2021. FSD appeared to be higher in hypertensive women than in normotensive women. Beta-blockers are the only antihypertensive agents with relatively strong evidence of damaging the female sexual function. Angiotensin receptor blockers (ARB) are relatively beneficial to female sexual function. To treat FSD in the presence of hypertension, controlling blood pressure is key, and the administration of angiotensin receptor blockers is preferred. In addition to controlling blood pressure, for premenopausal women, flibanserin and bremelanotide can be tried, while ospemifene and hormone supplements are preferred for postmenopausal women.

Hypertension and reproductive dysfunction: a possible role of inflammation and inflammation-associated lymphangiogenesis in gonads

Hypertension is one of the most prevalent diseases that leads to end organ damage especially affecting the heart, kidney, brain, and eyes. Numerous studies have evaluated the association between hypertension and impaired sexual health, in both men and women. The detrimental effects of hypertension in men includes erectile dysfunction, decrease in semen volume, sperm count and motility, and abnormal sperm morphology. Similarly, hypertensive females exhibit decreased vaginal lubrication, reduced orgasm, and several complications in pregnancy leading to fetal and maternal morbidity and mortality. The adverse effect of hypertension on male and female fertility is attributed to hormonal imbalance and changes in the gonadal vasculature. However, mechanistic studies investigating the impact of hypertension on gonads in more detail on a molecular basis remain scarce. Hence, the aim of the current review is to address and summarize the effects of hypertension on reproductive health, and highlight the importance of research on the effects of hypertension on gonadal inflammation and lymphatics.

Protective effects of irbesartan and benazepril against vaginal vascular remodeling and fibrosis in female spontaneously hypertensive rats

Objective

To compare the potential beneficial effects of the angiotensin converting enzyme inhibitor (ACEI) benazepril and the angiotensin II receptor 1 blocker (ARB) irbesartan on vaginal vascular remodeling and fibrosis in female spontaneously hypertensive rats (SHRs).

Methods

Twelve-week-old female SHRs were treated with irbesartan or benazepril for 12 weeks. Vaginal renin angiotensin system (RAS) components were detected by polymerase chain reaction and western blot and vaginal α-smooth muscle actin (α-SMA), endothelial nitric oxide synthase (eNOS), and collagen III (Col III) were analyzed by western blot. Vaginal tissue sections were examined by hematoxylin and eosin staining, Masson trichrome staining, and immunohistochemical analysis of α-SMA and Col III.

Results

Irbesartan and benazepril had different impacts on vaginal RAS components. Both agents decreased vaginal α-SMA and Col III and increased eNOS expression in SHR. The wall/lumen thickness ratio of vaginal arterioles was similarly decreased following irbesartan and benazepril treatment. Both drugs also decreased collagen deposition in SHRs. There was no difference in vaginal vascular remodeling or fibrosis between the two groups.

Conclusions

Irbesartan and benazepril have different effects on vaginal RAS expression but similar positive effects against vaginal vascular remodeling and fibrosis.

The Evolution of the Female Sexual Disorder/Dysfunction Definitions, Nomenclature, and Classifications: A Review of DSM, ICSM, ISSWSH, and ICD

INTRODUCTION

The 2 most well-known classification systems that include sexual medicine diagnoses are the International Classification of Diseases and Statistics (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). Sexual medicine experts from international societies representing an array of disciplines have revised and redefined female sexual dysfunctions (FSDs) to reflect current scientific evidence and the state of the art.

AIM

To summarize the evidence and interactive and chronological process by which sexual medicine societies' consensus groups developed the current nomenclature, classifications, and definitions for FSDs.

METHODS

We review the contributions and collaborations of the Fourth International Consultation in Sexual Medicine (ICSM), the International Society for the Study of Women's Sexual Health (ISSWSH), and the World Association of Sexual Health in conjunction with the World Health Organization.

MAIN OUTCOME MEASURES

The ICSM and ISSWSH diagnostic systems are contrasted with the DSM classification. We discuss innovations and strengths; relevant evidence regarding epidemiology, etiology, and risk factors; and key differences. We describe how sexual medicine expertise informed FSD codes in the ICD-11 classification.

RESULTS

ICSM and ISSWSH published evidence-based guidelines on the definitions, nomenclature, and diagnostic criteria for FSD that diverge from the DSM psychiatric compendia. These definitions and nomenclature recommend the separation of female sexual desire and arousal disorders, elaborate on subtypes of arousal problems, broaden the scope of sexual pain definitions, and provide a greater understanding of etiologies and risk factors for FSDs.

CONCLUSIONS

These collaborations among sexual medicine experts and their role in the ICD-11 development process provide confidence that the ICD-11 Sexual Dysfunction codes are based on current scientific evidence for diagnosing and coding FSDs in clinical settings worldwide, can serve as endpoints in clinical trials, and will provide specificity for treatment outcomes for FSD therapies. Parish SJ, Cottler-Casanova S, Clayton AH, et al. The Evolution of the Female Sexual Disorder/Dysfunction Definitions, Nomenclature, and Classifications: A Review of DSM, ICSM, ISSWSH, and ICD. Sex Med 2021;9:36-56.

Prevalence of Hypoactive Sexual Desire Disorder Among Sexually Active Postmenopausal Women With Metabolic Syndrome at a Public Hospital Clinic in Brazil: A Cross-sectional Study

Aims

To evaluate the prevalence of hypoactive sexual desire disorder (HSDD) among postmenopausal women diagnosed with metabolic syndrome (MS) and to compare it to that of a control group without MS.

Methods

This is a cross-sectional study carried out in 2 public tertiary hospitals in the state of São Paulo, Brazil, with a sample of 291 postmenopausal women aged between 40 and 65 years. Sexual function was evaluated using the Female Sexual Function Index (FSFI) questionnaire and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, diagnostic criteria and was related to the diagnosis of MS, which was determined according to the guidelines defined by the Adult Treatment Panel.

Main outcome measures

Analysis of sexual function with emphasis on sexual desire (HSDD), the incidence of MS, and the components of MS.

Results

The prevalence of HSDD was significantly higher among women diagnosed with MS than among women without MS (P = .01). Women diagnosed with high blood pressure (P < .01) and increased triglycerides (P = .03) also had a higher prevalence of HSDD than did women without these conditions. The FSFI domain scores for desire, arousal, lubrication, orgasm, and satisfaction and the total FSFI score were significantly lower for postmenopausal women with MS, whereas the pain domain score was not significantly different between the groups (P = .913). The incidence of female sexual dysfunction was significantly higher among women with MS, regardless of the diagnostic criteria used (P < .05).

Conclusion

Postmenopausal women diagnosed with MS have higher rates of HSDD than do women without MS.

Clinical Trial Registration: ID NCT02430987.

Dutra da Silva GM, Rolim Rosa Lima SM, Reis BF, et al. Prevalence of Hypoactive Sexual Desire Disorder Among Sexually Active Postmenopausal Women With Metabolic Syndrome at a Public Hospital Clinic in Brazil: A Cross-sectional Study. J Sex Med 2020;8:545–553.

Sexual function through decades: association with androgens and cardiometabolic features

Aim: This study aimed to determine the change in sexual function among Turkish women through decades and to define the association between sexual dysfunction and androgens and cardiometabolic features.Materials and methods: A total of 206 postmenopausal women aged 50-69 years and 210 premenopausal women aged 30-49 years who applied to menopause and gynecology clinics at a university-affiliated education and research hospital were included in this prospective study. Groups were constructed according to decades (i.e., 30-39, 40-49, 50-59, and 60-69 years). Sexual function was assessed between the groups, using the Female Sexual Function Index (FSFI). Cardiometabolic features and androgen levels were also compared between the groups.Results: Sexual function determined at each decade by FSFI scores were 27.18, 23.11, 18.40, and 11.35, respectively (fourth, fifth, sixth, and seventh decade). Desire, arousal, and satisfaction domains tended to be lower in the 40s than in the 30s. As time passes after the 30s, the total FSFI score decreased until the late 60s. Serum total testosterone, androstenedione, and dehydroepiandrostenedione sulfate (DHEAS) levels decreased through the decades. There was no correlation between cardiometabolic features, androgens, and FSFI scores.Conclusion: According to our survey, sexual function decreases starting at the age of 30 and continues to drop until the late 60s among postmenopausal women. There was no association between sexual dysfunction and androgen levels in premenopausal women. The serum DHEAS level was associated with sexual dysfunction only among postmenopausal women. There was no association between sexual dysfunction and cardiometabolic features in either premenopausal or postmenopausal women.

Systematic Review and Meta-Analysis for Sexual Dysfunction in Women With Hypertension

INTRODUCTION

Sexual dysfunction in hypertensive women is an often-neglected subject despite a reported prevalence of 42.1%. Although few reviews exist, a definitive relationship between hypertension and sexual dysfunction in women has not been clearly established.

AIM

To review the existing literature to definitively examine sexual dysfunction in women with hypertension, in both treated and untreated subjects.

METHODS

We performed a systematic search for published literature of 3 electronic databases (Scopus, EBSCOhost Medline Complete, and Cochrane Library) in August 2018. The search terms with relevant truncation and Boolean were developed according to a population exposure-comparator-outcome model combining pilot searches. The quality of included studies was assessed with the McMaster Critical Review Form for Quantitative Studies. Initial search, limited to the English language, included a total of 2,198 studies. 31 studies (18,260 subjects) met our inclusion criteria and were included in the review. Sexual dysfunction in these studies was measured using different tools. We extracted information of study setting, country, number of subjects, participants' age and blood pressure, comparators, and outcome. We ran a meta-analysis on the presence of sexual dysfunction as an outcome from the following comparisons: (i) hypertensive vs normotensive (ii) treated vs untreated hypertension, and (iii) exposure vs absence of specific class of anti-hypertensive drug.

MAIN OUTCOME MEASURES

Women with sexual dysfunction and hypertension were included.

RESULTS

We found significant sexual dysfunction in women with hypertension compared with the normotensive group (pooled odds ratio [OR] = 2.789, 95% CI = 1.452-5.357, P = .002). However, there was no statistical difference of sexual dysfunction in women with treated or untreated hypertension (OR = 1.229, 95% CI = 0.675-2.236, P = .5). Treatment with alpha-/beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and diuretics resulted in no statistical difference in sexual dysfunction in hypertensive women.

CLINICAL IMPLICATIONS

Because sexual dysfunction is prevalent in women with hypertension, it is imperative to address the underlying medical condition to manage this important clinical problem.

STRENGTH & LIMITATIONS

Many studies had to be excluded from the meta-analysis, due to unavailability and incompleteness of data. Nevertheless, results of the review are useful to derive recommendations for alerting physicians of the need to routinely assess the sexual functioning of women with hypertension.

CONCLUSION

We conclude that women with hypertension are at increased risk for sexual dysfunction, and our findings imply that evaluation for sexual dysfunction needs to be part of the clinical management guidelines for women with hypertension. Choy CL, Sidi H, Koon CS, et al. Systematic Review and Meta-Analysis for Sexual Dysfunction in Women With Hypertension. J Sex Med 2019;16:1029-1048.

Sexual Dysfunction in Women with Hypertension: a Systematic Review and Meta-analysis

PURPOSE OF REVIEW

We aimed to evaluate the prevalence of sexual dysfunction in hypertensive women and compare sexual dysfunction between hypertensive and non-hypertensive women.

RECENT FINDINGS

Conducted a systematic review in the following databases: PubMed, EMBASE, Scopus, Web of Science, IBECS, and Lilacs. We included articles evaluating the prevalence of sexual dysfunction in a woman and/or comparing sexual dysfunction between hypertensive and non-hypertensive women. Studies were excluded if they evaluated patients with secondary hypertension, examined sexual dysfunction caused by drugs, did not distinguish by gender, or included patients with hypertension and other comorbidities/pathologies. We conducted an I² test to calculate heterogeneity and a meta-analysis to compare sexual dysfunction between hypertensive and non-hypertensive women. A meta-regression equation calculated the relationship between sexual dysfunction risk for hypertensive and age. Eleven articles were included: five were included in the meta-analysis (1057 hypertensive and 715 normotensive). The prevalence of sexual dysfunction in articles varied from 14.1 to 90.1%. In the meta-analysis of the sexual dysfunction, the relative risk between hypertensive and normotensive women was found to be significant and has a high heterogeneity (I² =92.6%, p < 0.001); the pooled results revealed a significant risk ratio of 1.81 (95% CI 1.10-2.97, p < 0.05). The relative risk for hypertensive women showed an association with age (b = 0.0333, p < 0.0001). The studies analyzed presented significant limitations in relation to methodology and a small sample size. Consequently, the meta-analysis was highly heterogeneous and reinforced the need for further research in this area.

The association between sexual dysfunction and metabolic syndrome among Turkish postmenopausal women

Objective: The aim of this study is to determine the association between sexual dysfunction and metabolic syndrome (MS) among Turkish postmenopausal women Methods: In total, 290 postmenopausal women between the ages of 50 and 70 years and 265 premenopausal women between the ages of 30 and 49 years who applied to Menopause and Gynecology Clinics at Marmara University-affiliated Pendik Education and Research Hospital, Istanbul, Turkey were included in this prospective survey. Sexual function was assessed using the Female Sexual Function Index (FSFI). A FSFI total score of <26.5 was suggestive of sexual dysfunction. MS was assessed by the National Cholesterol Education Program Adult Treatment Panel III criteria. Results: Sexual dysfunction prevalence among postmenopausal women was 64.6% in relation to 42.1% in premenopausal women (p = 0.001). MS prevalence was 13.5% among premenopausal women and 15.5% among postmenopausal women (p = 0.57). The total FSFI score and each score in the desire, arousal, lubrication, orgasm, satisfaction, and dyspareunia domains of the FSFI did not differ between premenopausal and postmenopausal women, regarding the MS status. In the premenopausal group, 45.7% of women without MS and 37% of women with MS had lower sexual dysfunction (p = 0.40); whereas in the postmenopausal group, 62.2% of women without MS and 77.4% of women with MS had lower sexual function (p = 0.22). Conclusion: In our study population, the rate of sexual dysfunction increased in postmenopausal women in contrast to premenopausal women. The MS status did not make a difference in terms of sexual dysfunction either in premenopausal or postmenopausal women. Since our survey was conducted in a tertiary medical center which gave medical care service to women from middle and low socioeconomic classes, our results should be confirmed by a large multicenter survey enrolling women from all different socioeconomic classes.

The Impact of Metabolic Syndrome and Its Components on Female Sexual Dysfunction: A Narrative Mini-Review

Background

The impact of metabolic syndrome on female sexual dysfunction received modest consideration in clinical practice. The aim of the research was to analyze the international literature to determine the relationship between the metabolic syndrome, its components and female sexual disorders.

Methods

We identified relevant full-length papers by electronic databases as Index Medicus/Medline, Scopus, Life Science Journals, from 2005 to the present. Studies were searched using the following as search query: metabolic syndrome, female sexual dysfunction, obesity, systemic arterial hypertension, diabetes mellitus, dyslipidemia.

Results

Women with metabolic syndrome showed higher prevalence of sexual inactivity and low sexual desire, orgasm and satisfaction respect to women without metabolic syndrome. Particularly metabolic components as diabetes mellitus, dy-slipidemia, systemic arterial hypertension were strongly associated with lower sexual desire, activity and Female Sexual Function Index total score. In contrast, other studies showed no relationship.

Conclusion

Our study showed that in the clinical evaluation of women with metabolic syndrome routine inquiring about female sexual dysfunction should be recommended to ameliorate sexual function and quality of life. However more prospective and longitudinal studies on the sexual effects of metabolic syndrome should also be suggested to know the factors related to women's sexuality better.

Hypertension as a risk factor for female sexual dysfunction: cross-sectional study

OBJECTIVE

to evaluate the sexual dysfunction in hypertensive patients compared to normotensive patients.

METHOD

this was a cross-sectional study. Samples were composed of 54 hypertensive patients and 54 normotensive patients. The female sexual dysfunction was evaluated by the Female Sexual Function Index (FSFI).

RESULTS

the average FSFI score differed highly between hypertensive and normotensive patients (22.4± 7.4 versus 26.8 ±5.4, p< 0.001). Among hypertensive patients, 63% showed sexual dysfunction in opposition to 39% of normotensive patients (p=0.02). Hypertensive women had 1.67 more chances of showing the dysfunction than women with normal blood pressure.

CONCLUSION

the sexual dysfunction prevalence is higher in hypertensive than in normotensive women hence, hypertension is a potentiator factor for female sexual dysfunction.

Cardiometabolic Risk and Female Sexuality-Part I. Risk Factors and Potential Pathophysiological Underpinnings for Female Vasculogenic Sexual Dysfunction Syndromes

INTRODUCTION

Erectile dysfunction is recognized as an opportunity for preventing cardiovascular (CV) events, and assessing the impairment of penile vascular flow by Doppler ultrasound is an important tool to ascertain CV risk. Conversely, the role of genital vascular impairment in the pathophysiology of female sexual dysfunction (FSD) remains contentious.

AIM

To focus on the current scientific support for an association between CV risk factors and female sexual health in the 1st part of a 2-part review.

METHODS

A thorough literature search of peer-reviewed publications on the associations between CV risk factors and FSD and their underlying mechanisms was performed using the PubMed database.

MAIN OUTCOME MEASURES

We present a summary of the evidence from clinical studies and discuss the possible mechanisms providing the pathophysiologic bases of vasculogenic FSD syndromes.

RESULTS

The peripheral sexual response in women is a vascular-dependent event, and evidence suggests that cardiometabolic-related perturbations in endothelial function can determine vascular insufficiency in female genital tissues. Although epidemiologic and observational studies demonstrate that the prevalence of FSD is higher in women with diabetes mellitus, a cause-effect relation between these clinical conditions cannot be assumed. Evidence on the effect of obesity, metabolic syndrome, and polycystic ovary syndrome on sexual function in women is controversial. Data on the associations of dyslipidemia and hypertension with FSD are limited.

CONCLUSION

Common cardiometabolic alterations could affect vascular function in the female genital tract. Based on limited data, there is an association between CV risk factors and female sexual health in women; however, this association appears milder than in men. Maseroli E, Scavello I, Vignozzi L. Cardiometabolic Risk and Female Sexuality-Part I. Risk Factors and Potential Pathophysiological Underpinnings for Female Vasculogenic Sexual Dysfunction Syndromes. Sex Med Rev 2018;6:508-524.

Association Between Sexual Problems and Relationship Satisfaction Among People With Cardiovascular Disease

BACKGROUND

Relationship satisfaction is generally positively correlated with sexual satisfaction, but this relation has been poorly examined in people with cardiovascular disease who are at increased risk of sexual problems compared with the general population.

AIM

To document reported changes to sex after a diagnosis of cardiac disease and determine whether there is an association between sexual function and relationship satisfaction.

METHODS

Semistructured telephone interviews focused on relationship satisfaction and sexual problems were conducted with 201 people with cardiovascular disease who were currently in a sexual relationship with one main partner and were recruited from six hospital cardiac rehabilitation centers in Ireland. Comparisons between groups were conducted using t-tests and multivariate analysis of variance for continuous variables and χ² tests for categorical variables. Predictors of relationship satisfaction were assessed using multiple linear regression analysis.

OUTCOMES

Data were gathered on demographic and clinical variables, sexual problems, and relationship satisfaction, including satisfaction with the physical, emotional, affection, and communication aspects of relationships.

RESULTS

Just less than one third of participants (n = 61, 30.3%) reported that sex had changed for the worse since their cardiac event or diagnosis, with approximately half of these stating that this was a serious problem for them. Satisfaction with relationships was high among patients surveyed; more than 70% of the sample reported being very or extremely satisfied with the physical and emotional aspects and showing affection during sex. Satisfaction with communication about sex was lower, with only 58% reporting being very or extremely satisfied. We did not find significant associations between reporting of sexual problems or deterioration of sex as a result of disease and relationship satisfaction.

CLINICAL IMPLICATIONS

Cardiac rehabilitation programs should address these sexual problems, potentially by enhancing communication within couples about sex.

STRENGTHS AND LIMITATIONS

The strength is that data are presented on the sexual experiences and relationship satisfaction of a relatively large sample of people diagnosed with cardiac disease, a relatively underexplored research area. Limitations include the possibility of selection bias of study participants and bias associated with self-report measurement.

CONCLUSIONS

Sexual problems were significant in this population but were not related to relationship satisfaction in this cross-sectional survey. Byrne M, Murphy P, D'Eath M, et al. Association Between Sexual Problems and Relationship Satisfaction Among People With Cardiovascular Disease. J Sex Med 2017;14:666-674.

Attitudes and Performance of Cardiologists Toward Sexual Issues in Cardiovascular Patients

Introduction

The aim of the present study was to evaluate the attitudes and performance of cardiologists regarding sexual issues in patients with cardiovascular diseases.

Methods

A nationwide survey was conducted in a sample of cardiologists, representative of Iranian cardiologists, in 2015.

Main Outcome Measures

Appropriate questionnaires were developed and used to ask participants about their attitudes, performance, and barriers regarding discussing sexual issues with patients with cardiovascular disease.

Results

The study population consisted of 202 cardiologists (138 men and 63 women) with a mean age of 44.25 years (SD = 8.45). Overall, 93.15% of cardiologists agreed with the importance of discussing sexual issues with their patients with cardiovascular diseases. Almost 76.7% of cardiologists agreed they had a responsibility to deal with patients' sexual problems, and 79.9% of them were aware of the association of cardiovascular disease with sexual problems of cardiac patients, but only 33% of them were confident in their knowledge and skills in this regard. Only 10.6% of cardiologists reported they frequently or always assessed sexual problems with their patients, but 51.50% of them stated they were responding to patients' questions about sexual problems. There was a significant association between performance and responsibility.

Conclusion

The results of this study indicate a gap between cardiologist's attitudes and their actual performance and that their professional responsibility to address patients' sexual issues is a significant parameter for better performance.

Implementing international sexual counselling guidelines in hospital cardiac rehabilitation: development of the CHARMS intervention using the Behaviour Change Wheel

BACKGROUND

Decreased sexual activity and sexual problems are common among people with cardiovascular disease, negatively impacting relationship satisfaction and quality of life. International guidelines recommend routine delivery of sexual counselling to cardiac patients. The Cardiac Health and Relationship Management and Sexuality (CHARMS) baseline study in Ireland found, similar to international findings, limited implementation of sexual counselling guidelines in practice. The aim of the current study was to develop the CHARMS multi-level intervention to increase delivery of sexual counselling by healthcare professionals. We describe the methods used to develop the CHARMS intervention following the three phases of the Behaviour Change Wheel approach: understand the behaviour, identify intervention options, and identify content and implementation options. Survey (n = 60) and focus group (n = 14) data from two previous studies exploring why sexual counselling is not currently being delivered were coded by two members of the research team to understand staff's capability, opportunity, and motivation to engage in the behaviour. All potentially relevant intervention functions to change behaviour were identified and the APEASE (affordability, practicability, effectiveness, acceptability, side effects and equity) criteria were used to select the most appropriate. The APEASE criteria were then used to choose between all behaviour change techniques (BCTs) potentially relevant to the identified functions, and these BCTs were translated into intervention content. The Template for Intervention Description and Replication (TIDieR) checklist was used to specify details of the intervention including the who, what, how and where of proposed intervention delivery.

RESULTS

Providing sexual counselling group sessions by cardiac rehabilitation staff to patients during phase III cardiac rehabilitation was identified as the target behaviour. Education, enablement, modelling, persuasion and training were selected as appropriate intervention functions. Twelve BCTs, linked to intervention functions, were identified for inclusion and translated into CHARMS intervention content.

CONCLUSIONS

This paper details the use of Behaviour Change Wheel approach to develop an implementation intervention in an under-researched area of healthcare provision. The systematic and transparent development of the CHARMS intervention will facilitate the evaluation of intervention effectiveness and future replication and contribute to the advancement of a cumulative science of implementation intervention design.

Cardiometabolic Risk and Female Sexuality: Focus on Clitoral Vascular Resistance

INTRODUCTION

The relation between sexual and cardiovascular health in women is not well defined. Clitoral color Doppler ultrasound (CDU) with assessment of the pulsatility index (PI), reflecting resistance to blood flow, has been proposed as an objective measurement of sexual functioning.

AIM

To investigate associations between clitoral PI and cardiometabolic risk factors, sexual and intrapsychic parameters, and self-perception of body image.

METHODS

Seventy-one adult heterosexual women in a stable relationship attending our clinic for sexual dysfunction were consecutively recruited.

MAIN OUTCOME MEASURES

Patients underwent physical, laboratory, and clitoral color Doppler ultrasound examinations and completed the Female Sexual Function Index, the Middlesex Hospital Questionnaire, and the Body Uneasiness Test (BUT).

RESULTS

Clitoral PI was positively correlated with body mass index (r = 0.441, P < .0001), waist circumference (r = 0.474, P < .0001), glycemia (r = 0.300, P = .029), insulin (r = 0.628, P = .002), homeostatic model assessment index (r = 0.605, P = .005), triglycerides (r = 0.340, P = .011), total cholesterol (r = 0.346, P = .010), and low-density lipoprotein cholesterol (r = 0.334, P = .016). All relations, with the exception of glycemia, retained statistical significance after adjusting for age, smoking habit, and years since menopause (P < .0001 for body mass index, waist circumference, and triglycerides; P < .05 for all other associations). Analysis of covariance, after adjusting for confounders, showed that women with obesity or metabolic syndrome (MetS) showed significantly higher PI values (obesity: F = 17.79, P = .001; MetS: F = 7.37, P = .019). In particular, a stepwise increase of PI was found as a function of increasing MetS components (β = 0.434, P = .007). Clitoral PI was negatively associated with Female Sexual Function Index arousal (β = -0.321, P = .014) and satisfaction (β = -0.289, P = .026) scores and positively associated with Middlesex Hospital Questionnaire somatized anxiety symptoms, even after adjusting for age, smoking habit, years since menopause, and current use of psychiatric medication (β = 0.354, P = .011). A positive association also was observed between PI and the BUT positive symptom distress index (β = 0.322, P = .039) and BUT for dislike of the womb, genitals, and breast (β = 0.538, P < .0001; β = 0.642, P < .0001; β = 0.549, P < .0001, respectively). After introducing waist circumference as another covariate, the associations between clitoral PI and the BUT positive symptom distress index and BUT dislike of the womb, genitals, and breast retained statistical significance (P = .038 for positive symptom distress index; P < .0001 for dislike of womb, genitals, and breast).

CONCLUSION

Clitoral vascular resistance is positively associated with MetS (in particular insulin resistance), decreased sexual arousal, body image concerns, and increased somatized anxiety symptoms. Further studies are needed to establish whether treatment of metabolic abnormalities might improve clitoral color Doppler ultrasound indices and sexual outcomes.

Impaired Lipid Profile is a Risk Factor for the Development of Sexual Dysfunction in Women

INTRODUCTION

Dyslipidemia is a common risk factor for cardiovascular disease which may contribute to sexual dysfunction in women.

AIMS

To assess the impact of dyslipidemia compared with other metabolic alterations on female sexual function.

METHODS

In total, 466 women were enrolled in the study, of which 256 were postmenopausal. Dyslipidemia was defined based on high-density lipoprotein, low-density lipoprotein, or triglycerides levels. Women completed the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale (FSDS), and the Middlesex Hospital Questionnaire (MHQ). Biochemical and anthropometric measurements were performed and the Framingham risk score (FRS) was calculated for each subject.

MAIN OUTCOME MEASUREMENTS

FSFI, FSDS, and MHQ scores, prevalence of FSD and FRS.

RESULTS

Median age of the population enrolled was 51.5 (range 42.0-58.0) years. The overall prevalence of FSD, according to FSFI and FSDS scores, was 24%. A significantly higher prevalence of FSFI (P = .001) and FSDS (P = .006) pathological scores were found in women with dyslipidemia compared with the control group. The prevalence of FSD was significantly higher in dyslipidemic women (P = .001). Women with dyslipidemia had significantly higher total scores in areas of depression, somatization, and obsession in the MHQ questionnaire compared with control women. Multivariate analysis showed that dyslipidemia (OR:1.7, CI 1.1-2.9, P = .037), postmenopausal status (OR:2.7, CI 1.5-4.7, P = .001), higher education (OR:0.6; CI 0.3-0.9, P = .038), and somatization (OR:1.7, CI 1.0-2.8, P = .045) were independently associated with FSD. The FRS was higher in dyslipidemic women (P = .001) and in those with FSD (P = .001), being associated with an almost doubled risk of developing FSD.

CONCLUSION

Our results indicate that dyslipidemia is an independent risk factor for FSD irrespective of postmenopausal status. Also, psychopathological alterations such as somatization are strongly associated with sexual dysfunction. The direct correlation between FSFI score and FRS suggest the importance of cardiovascular integrity in female sexual health.

Sexual counselling for patients with cardiovascular disease: protocol for a pilot study of the CHARMS sexual counselling intervention

INTRODUCTION

Sexual problems are common with cardiovascular disease, and can negatively impact quality of life. To address sexual problems, guidelines have identified the importance of sexual counselling during cardiac rehabilitation, yet this is rarely provided. The Cardiac Health and Relationship Management and Sexuality (CHARMS) intervention aims to improve the provision of sexual counselling in cardiac rehabilitation in Ireland.

METHODS AND ANALYSIS

This is a multicentre pilot study for the CHARMS intervention, a complex, multilevel intervention delivered within hospital-based cardiac rehabilitation programmes. The intervention includes (1) training in sexual counselling for staff, (2) a staff-led patient education and support intervention embedded within the cardiac rehabilitation programme, (3) a patient information booklet and (4) an awareness raising poster. The intervention will be delivered in two randomly selected cardiac rehabilitation centres. In each centre 30 patients will be recruited, and partners will also be invited to participate. Data will be collected from staff and patients/partners at T1 (study entry), T2 (3-month follow-up) and T3 (6-month follow-up). The primary outcome for patients/partners will be scores on the Sexual Self-Perception and Adjustment Questionnaire. Secondary outcomes for patients/partners will include relationship satisfaction; satisfaction with and barriers to sexual counselling in services; sexual activity, functioning and knowledge; physical and psychological well-being. Secondary outcomes for staff will include sexuality-related practice; barriers to sexual counselling; self-ratings of capability, opportunity and motivation; sexual attitudes and beliefs; knowledge of cardiovascular disease and sex. Fidelity of intervention delivery will be assessed using trainer self-reports, researcher-coded audio recordings and exit interviews. Longitudinal feasibility data will be gathered from patients/partners and staff via questionnaires and interviews.

ETHICS AND DISSEMINATION

This study is approved by the Research Ethics Committee (REC) of the National University of Ireland, Galway. Findings will be disseminated to cardiac rehabilitation staff, patients/partners and relevant policymakers via appropriate publications and presentations.

Sexual counselling for sexual problems in patients with cardiovascular disease

BACKGROUND

Sexual problems are common among people with cardiovascular disease. Although clinical guidelines recommend sexual counselling for patients and their partners, there is little evidence on its effectiveness.

OBJECTIVES

To evaluate the effectiveness of sexual counselling interventions (in comparison to usual care) on sexuality-related outcomes in patients with cardiovascular disease and their partners.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, and three other databases up to 2 March 2015 and two trials registers up to 3 February 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs, including individual and cluster RCTs. We included studies that compared any intervention to counsel adult cardiac patients about sexual problems with usual care.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included three trials with 381 participants. We were unable to pool the data from the included studies due to the differences in interventions used; therefore we synthesised the trial findings narratively.Two trials were conducted in the USA and one was undertaken in Israel. All trials included participants who were admitted to hospital with myocardial infarction (MI), and one trial also included participants who had undergone coronary artery bypass grafting. All trials followed up participants for a minimum of three months post-intervention; the longest follow-up timepoint was five months.One trial (N = 92) tested an intensive (total five hours) psychotherapeutic sexual counselling intervention delivered by a sexual therapist. One trial (N = 115) used a 15-minute educational video plus written material on resuming sexual activity following a MI. One trial (N = 174) tested the addition of a component that focused on resumption of sexual activity following a MI within a hospital cardiac rehabilitation programme.The quality of the evidence for all outcomes was very low.None of the included studies reported any outcomes from partners.Two trials reported sexual function. One trial compared intervention and control groups on 12 separate sexual function subscales and used a repeated measures analysis of variance (ANOVA) test. They reported statistically significant differences in favour of the intervention. One trial compared intervention and control groups using a repeated measures analysis of covariance (ANCOVA), and concluded: "There were no significant differences between the two groups [for sexual function] at any of the time points".Two trials reported sexual satisfaction. In one trial, the authors compared sexual satisfaction between intervention and control and used a repeated measured ANOVA; they reported "differences were reported in favour of the intervention". One trial compared intervention and control with a repeated measures ANCOVA and reported: "There were no significant differences between the two groups [for sexual satisfaction] at any of the timepoints".All three included trials reported the number of patients returning to sexual activity following MI. One trial found some evidence of an effect of sexual counselling on reported rate of return to sexual activity (yes/no) at four months after completion of the intervention (relative risk (RR) 1.71, 95% confidence interval (CI) 1.26 to 2.32; one trial, 92 participants, very low quality of evidence). Two trials found no evidence of an effect of sexual counselling on rate of return to sexual activity at 12 week (RR 1.01, 95% CI 0.94 to 1.09; one trial, 127 participants, very low quality of evidence) and three month follow-up (RR 0.98, 95% CI 0.88 to 1.10; one trial, 115 participants, very low quality of evidence).Two trials reported psychological well-being. In one trial, no scores were reported, but the trial authors stated: "No treatment effects were observed on state anxiety as measured in three points in time". In the other trial no scores were reported but, based on results of a repeated measures ANCOVA to compare intervention and control groups, the trial authors stated: "The experimental group had significantly greater anxiety at one month post MI". They also reported: "There were no significant differences between the two groups [for anxiety] at any other time points".One trial reporting relationship satisfaction and one trial reporting quality of life found no differences between intervention and control.No trial reported on satisfaction in how sexual issues were addressed in cardiac rehabilitation services.

AUTHORS' CONCLUSIONS

We found no high quality evidence to support the effectiveness of sexual counselling for sexual problems in patients with cardiovascular disease. There is a clear need for robust, methodologically rigorous, adequately powered RCTs to test the effectiveness of sexual counselling interventions for people with cardiovascular disease and their partners.

Sexuality and psychopathological aspects in premenopausal women with metabolic syndrome

INTRODUCTION

Metabolic syndrome (MetS) is a cluster of cardiovascular risk factors that have been suggested to impact female sexual function.

AIMS

This study aims to assess the prevalence of female sexual dysfunction (FSD) in premenopausal women with MetS compared with healthy controls (HC). Psychopathological aspects and the relationship to FSD were also evaluated in both groups.

METHODS

Two hundred four premenopausal women, of whom 98 had diagnosis of MetS, were asked to complete the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale (FSDS), and the Middlesex Hospital Questionnaire (MHQ). Routine laboratory tests and anthropometric measurements were routinely performed.

MAIN OUTCOME MEASURES

FSFI and FSDS questionnaires, prevalence of FSD, and MHQ scores.

RESULTS

In the MetS group compared with the HC group, we found: a lower global FSFI score (P=0.005), higher prevalence of pathological scores compared with HC group, and lower scores in the desire, arousal, lubrication, and orgasm domains. An inverse correlation between the FSFI score and the number of risk factors for MetS was detected. MetS women reported significantly higher total scores in the somatization and depression domains when compared with the HC group. The logistic regression showed that high triglycerides (odds ratio [OR] 3.097; 95% confidence interval [CI] 1.272-7.542; P=0.026) and somatization (OR 7.068; CI 95% 2.291-21.812; P=0.001) are independently associated with FSD in premenopausal women.

CONCLUSIONS

Our results indicate a higher prevalence of sexual dysfunction in MetS women. A number of risk factors for MetS are positively associated with FSD and higher triglycerides seem to be the strongest predictors of sexual dysfunction. Psychopathological dimensions such as somatization are strongly associated with sexual dysfunction.

Communicating about sexual concerns within cardiac health services: do service providers and service users agree?

OBJECTIVE

Sexual assessment and counselling is a recommended, yet underprovided and challenging, aspect of cardiac rehabilitation. We compared the views of cardiac healthcare providers and patients in terms of their experiences of communication about sexual issues.

METHODS

Cardiac patients (n=382) completed telephone surveys and hospital cardiac rehabilitation staff (n=60) and general practitioners (n=61) returned postal questionnaires.

RESULTS

Patients reported that sex was rarely discussed, yet nearly half of patients said they would have liked this opportunity. Most general practitioners (70%) reported not addressing sex with their patients and the majority of cardiac rehabilitators (almost 61%) reported that sexual problems were poorly addressed in their service. Patients perceived fewer barriers to communication (the main barrier was lack of privacy) than health professionals (the primary barrier for general practitioners was lack of time, and for cardiac rehabilitation staff, lack of training).

CONCLUSION

All participants agreed that sexual assessment and counselling is currently poorly implemented. A gap exists: patients, who generally want sexual issues to be addressed, perceive fewer barriers to communication than healthcare providers, who fear causing anxiety and discomfort by raising sexual issues with their patients.

PRACTICE IMPLICATIONS

Developing brief interventions for healthcare providers and information materials for patients are recommended.

Sexual self-perception and adjustment of cardiac patients: a psychometric analysis

The psychological impact of a cardiac event includes anxiety and depression, poor sexual quality, and diminished sexual satisfaction. Few measures capture psychosexual recovery following a cardiac event. This study evaluated the reliability and validity of the Sexual Self-Perception and Adjustment Questionnaire (SSPAQ) among cardiac patients ( N = 128), measuring sexual anxiety, depression, self-efficacy, and satisfaction. Scale-level content validity was 0.97. After item analysis, 28 items were retained; Cronbach’s alpha is >0.90, indicating item appropriateness for the combined scale (0.97). A four-factor model was supported with each of the subscale items accounting for at least 64% of the variance. Construct validity comparing sexually active to inactive showed those inactive had significantly lower sexual self-perception. The SSPAQ is a cohesive measure of sexual self-perception, and findings suggest each subscale can be used independently for measures of sexual anxiety, sexual depression, sexual self-efficacy, and sexual satisfaction, and may be useful in research and clinical settings.

Prevalence of sexual activity and associated factors in hypertensive males and females in China: a cross-sectional study

Background

Hypertension is an important factor contributing to sexual dysfunction. The number of people with hypertension is increasing in China, but research into sexual life, which has implications for quality of life, is limited. We aimed to compare sexual activity and the influence of daily behaviors and sexual domain of hypertensive males and females in south China.

Methods

A cross-sectional study was conducted at the health care center of a university-affiliated hospital from 2007 to 2008. We enrolled 502 subjects with hypertension (225 males, 48.79 ± 7.39 years old; 277 females, 48.26 ± 6.93 years old) and 173 with normotension (82 males, 45.69 ± 6.58 years old; 91 females, 46.14 ± 7.03 years old), all sexually active. All subjects completed a self-administered questionnaire on sexual activity before a routine physical check-up. Data were collected on sociodemographic and clinical characteristics, use of cigarettes and intake of beverages (including alcohol).

Results

Hypertensive and normotensive subjects differed in frequency of orgasms and of sexual satisfaction, as well as duration of sexual activity. For hypertensive men, low frequency of sexual activity, orgasms and satisfaction were associated with unemployed or retired status than physical labor work (odds ratio [OR] 0.28 [95% confidence interval (95% CI) 0.12–0.69], 0.32 [0.12–0.86], 0.33 [0.19–0.88], respectively; p < 0.05), and long sexual duration was associated with never drinking alcohol than heavy drinking (OR 4.49 [1.28–6.41]). For hypertensive women, low frequency and duration of sexual activity and low satisfaction were associated with never drinking tea than heavy tea drinking (OR 0.42 [0.18–0.96], 0.49 [0.24–0.98], 0.29 [0.14–0.64], respectively; p < 0.05). Medication use and electrocardiography results were not associated with sexual activity for hypertensive patients.

Conclusions

For hypertensive people in China, lifestyle factors are associated with sexual dysfunction, which differs by the sex of the person. Further research needs to examine serum hormone levels to validate the result.

Effect of felodipine with irbesartan or metoprolol on sexual function and oxidative stress in women with essential hypertension

OBJECTIVE

To evaluate the impact of felodipine with irbesartan on sexual function compared with felodipine with metoprolol in hypertensive women.

METHODS

This was a prospective, randomized, parallel, active-controlled, open-label study (ClinicalTrials.org: NCT01238705) in 160 women (18-60 years) with mild or moderate hypertension, randomized to a once-daily treatment with felodipine combined with irbesartan or metoprolol for 48 weeks. Patients' sexual function was evaluated using a female sexual function index (FSFI) questionnaire at baseline and after 24 and 48 weeks of therapy. Levels of serum estradiol, testosterone, 8-hydroxy-2'-deoxyguanosine (8-OHdG), 4-hydroxynonenal (4-HNE) and malondialdehyde (MDA) were measured.

RESULTS

The two combination regimens were similarly effective in lowering blood pressure. After 48 weeks, in felodipine-irbesartan group, total scores of FSFI improved (P < 0.001). Items showing improvement in scores corresponded to desire, arousal and orgasm (P < 0.001; P = 0.002; P = 0.049, respectively). Levels of estradiol increased under treatment with felodipine-irbesartan (P = 0.003) and decreased under felodipine-metoprolol treatment (P < 0.001). The concentration of testosterone declined after felodipine-irbesartan therapy (P < 0.001) and increased under felodipine-metoprolol treatment (P < 0.001). In the felodipine-irbesartan group, decreases of 8-OHdG, 4-HNE (P < 0.001) and MDA (P < 0.001) were observed. The felodipine-irbesartan combination resulted in less oxidative stress. The differences in changes in 8-OHdG, 4-HNE and MDA between the two groups were significant (P < 0.05).

CONCLUSION

These results suggested that the felodipine-irbesartan combination regimen improved sexual function in hypertensive women, whereas felodipine-metoprolol regiment did not. The reason for the different influence of these two combination therapy on female sexual function might be their different impacts on oxidative stress and hormone levels.