Sexual function in women. Do antihypertensive drugs have an impact?

Sex, Rhythm & Death: The effect of sexual activity on cardiac arrhythmias and sudden cardiac death

Arrhythmias and sudden cardiac death with sexual activity are rare. However, the demographics are changing regarding the cardiovascular patients at risk for these events. Recent studies have highlighted that the individuals having cardiac events during sexual activity are becoming younger, with a higher proportion of female decedents than previously described. There needs to be an open dialog between the cardiovascular team and the cardiac patient to provide the education and reassurance necessary for cardiovascular patients to participate in sexual intercourse safely. This paper reviews how sexual activity can lead to an increase in cardiac arrhythmias and sudden cardiac arrest in patients that are not medically optimized or are unaware of their underlying cardiac condition. The most common cardiovascular diseases associated with sexually induced arrhythmias and arrest are discussed regarding their potential risk and the psychosocial impact of this risk on these patients. Finally, cardiovascular medications and implantable cardioverter-defibrillators (ICDs) are addressed by reviewing the literature on the safety profile of these cardiac interventions in this patient population. Overall, sexual activity is safe for most cardiac patients, and providing proper education to the patient and their partner can improve the safety profile for patients with higher risk cardiovascular conditions. To give the appropriate education and reassurance necessary, cardiovascular team members need an understanding of the pathophysiology of how sexual activity can provoke arrhythmias and sudden cardiac arrest. Healthcare providers also need to build comfort in speaking to all patients and ensure that sexual partners, female patients, and those in the LGBTQIA + community receive the same access to counseling but tailored to their individual needs.

Sexual Activity in Patients with Cardiac Diseases

SUMMARY – In this article, we outline the latest guidelines published by the American Heart Association on sexual activity in patients with coronary artery disease, heart failure, structural heart diseases, arrhythmias, implanted pacemakers or cardioverter defibrillators, as well as on treatment options of sexual dysfunction. Sexual activities are similar to mild/moderate physical activity during a short period. Most patients are recommended to involve in sexual activity after prior comprehensive evaluation of physical condition. Those with stable cardiac symptoms and good functional capacity are at a low risk of adverse cardiovascular events, and others require treatment or stabilization before involving in sexual activity. Stress testing is useful in evaluating safety of sexual activity in patients with questionable or undetermined risk. Treatment of sexual dysfunction includes counseling of patients and their sexual partners, and drug treatment with phosphodiesterase inhibitors (sildenafil, tadalafil, vardenafil) which have been demonstrated to be safe and effective, in men, and with serotonin reuptake inhibitors (flibanserin) and local vaginal estrogen administration in women. In conclusion, in routine clinical practice, patients should be approached individually and multidisciplinarily in order to detect and eliminate the factors that interfere with normal sexual activities and disturb the quality of life.

A review of the positive and negative effects of cardiovascular drugs on sexual function: a proposed table for use in clinical practice

Several antihypertensive drugs, such as diuretics and β-blockers, can negatively affect sexual function, leading to diminished quality of life and often to noncompliance with the therapy. Other drug classes, however, such as angiotensin II receptor blockers (ARBs) are able to improve patients’ sexual function. Sufficient knowledge about the effects of these widely used antihypertensive drugs will make it possible for cardiologists and general practitioners to spare and even improve patients’ sexual health by switching to different classes of cardiac medication. Nevertheless, previous data (part I) indicate that most cardiologists lack knowledge about the effects cardiovascular agents can have on sexual function and will thus not be able to provide the necessary holistic patient care with regard to prescribing these drugs. To be able to improve healthcare on this point, we aimed to provide a practical overview, for use by cardiologists as well as other healthcare professionals, dealing with sexual dysfunction in their clinical practices. Therefore, a systematic review of the literature was performed. The eight most widely used classes of antihypertensive drugs have been categorised in a clear table, marking whether they have a positive, negative or no effect on sexual function.

Quality of life and psychological problems in patients undergoing neurological rehabilitation

Aim:

To assess the quality of life (QoL) and prevalence of psychological problems (PP) in patients with neurological illness, and their correlation with functional abilities.

Materials and Methods:

Prospective cross-sectional study conducted in the neurological rehabilitation unit of tertiary research hospital in 30 consecutive hospitalized patients (21 men), age 16-55 years (34.63±11.87).

Outcome Measure:

WHOQoL-BREF was used to assess QoL. The prevalence of PP was recorded using Hospital Anxiety Depression Scale (HADS) and General Health Questionnaire (GHQ-12). QoL and HADS scores were correlated with functional abilities using mean Barthel Index (BI) Score.

Results:

The duration of illness was three to 30 months (10.63±7.83) and their primary diagnoses were stroke 12, traumatic spinal cord injury seven and non-traumatic spinal cord lesion 11. Twenty-two patients qualified for GHQ-12 caseness, with 15 patients having distress (score ≥15) and seven having severe problem and psychological distress (score≥20). Twenty five patients had abnormal anxiety and 17 had abnormal depression on HADS (abnormal = 8-21), with moderate to severe anxiety and depression (scores≥11) in nine and three patients respectively. The mean WHOQoL-BREF transformed scores (on WHOQoL 0-100 scale) were (38.83±8.02), (50.76±9.79), (48.53±18.46) and (49.13±10.63) in physical, psychological, social, and environmental domains respectively. The social domain of QoL had significant correlation (P<.05) with functional abilities.

Conclusion:

Patients with neurological disorders requiring inpatient rehabilitation have impaired QoL that affects all domains of life. There is high prevalence of psychological problems, including anxiety and depression. The social domain of QoL adversely affected functional abilities, but the correlation between PP and functional abilities was insignificant.

Restoration of female genital vasocongestive arousal responses in young and aged rats

INTRODUCTION

Treatments of aged, male hypertensive rats that induce vascular remodeling or that normalize endothelial function are known to produce sustained improvements in erectile function. Whether the treatments targeting these processes benefit female genital vasocongestive arousal (GVA) responses is currently not known.

AIM

To determine whether the actions of nitric oxide (NO) are critical to the apomorphine (APO)-generated GVA responses in both intact and ovariectomized OVX young adult female rats (before any aging-associated decreases in the responses). In addition, we also investigated whether the diminished GVA responses in aged rats could be restored, at least in part, using an antihypertensive treatment, which is known to enhance erectile responses and improve general vascular function in male rats.

METHODS

In female Wistar rats, APO-induced GVA responses (80 microg/kg, subcutaneously [sc], 30 minutes) were assessed by videomonitoring following various treatments. Young adult females were ovariectomized or were treated with the nitric oxide synthase (NOS) inhibitor N-nitro-L-arginine methyl ester (30 mg/kg, iv), followed by an NO mimetic, sodium nitroprusside (10 microg/kg/minute, intravenous). Aged females (18 months) were treated for 2 weeks with the angiotensin converting enzyme (ACE) inhibitor, enalapril (30 mg/kg/day, orally) plus low sodium (0.04%).

MAIN OUTCOME MEASURES

APO-induced GVA responses in female rats.

RESULTS

There was an age-associated reduction in sexual responses in normotensive rats that was greatly enhanced (fourfold) by brief, aggressive antihypertensive treatment. The enhanced vasocongestive responses persisted for a 5-week off-treatment. Both OVX and NOS inhibition significantly decreased sexual responses by approximately 80% in young female rats. Systemic administration of an NO mimetic recovered vasocongestive responses in the NOS-blocked rats, but not in OVX animals.

CONCLUSIONS

Although mechanisms were not established, the major findings were that brief aggressive ACE inhibitor treatment markedly improved sexual responses in aged female rats, and systemic delivery of an NO mimetic recovered sexual responses in globally NOS-blocked animals.

Drug-Induced Endocrine and Metabolic Disorders

Complex interactions exist amongst the various components of the neuroendocrine system in order to maintain homeostasis, energy balance and reproductive function. These components include the hypothalamus-pituitary- adrenal and -gonadal axes, the renin-angiotensin-aldosterone system, the sympathetic nervous system and the pancreatic islets. These hormones, peptides and neurotransmitters act in concert to regulate the functions of many organs, notably the liver, muscles, kidneys, thyroid, bone, adrenal glands, adipocytes, vasculature, intestinal tract and gonads, through many intermediary pathways. Endocrine and metabolic disorders can arise from imbalance amongst numerous hormonal factors. These disturbances may be due to endogenous processes, such as increased secretion of hormones from a tumour, as well as exogenous drug administration. Drugs can cause endocrine abnormalities via different mechanisms, including direct alteration of hormone production, changes in the regulation of the hormonal axis, effects on hormonal transport, binding, and signalling, as well as similar changes to counter-regulatory hormone systems. Furthermore, drugs can affect the evaluation of endocrine parameters by causing interference with diagnostic tests. Common drug-induced endocrine and metabolic disorders include disorders of carbohydrate metabolism, electrolyte and calcium abnormalities, as well as drug-induced thyroid and gonadal disorders. An understanding of the proposed mechanisms of these drug effects and their evaluation and differential diagnosis may allow for more critical interpretation of the clinical observations associated with such disorders, better prediction of drug-induced adverse effects and better choices of and rationales for treatment.

Female sexual dysfunction in essential hypertension: a common problem being uncovered

OBJECTIVES

Female sexual dysfunction (FSD) is increasingly attracting more scientific and public interest, and represents a poorly investigated issue in patients with essential hypertension. We evaluated the prevalence of sexual dysfunction in hypertensive women compared with normotensive women according to age, hypertension severity, hypertension duration, and antihypertensive treatment.

METHODS

The study population consisted of consecutive, sexually active women attending an outpatient hypertension clinic. The Female Sexual Function Index (FSFI questionnaire) was used to evaluate FSD. Univariate and multivariate analyses were used to evaluate predictors of FSD.

RESULTS

Four hundred and seventeen women were studied. From them, 216 women had arterial hypertension (136 treated, 80 untreated) and 201 were normotensive. Sexual dysfunction was found in 42.1% of hypertensive women compared with 19.4% of normotensive women (odds ratio, 3.2; 95% confidence interval, 1.9-4.7; P < 0.001). Systolic blood pressure levels were significantly related to FSFI score (r = -0.67, P < 0.001). Successful control of hypertension was related to lower prevalence of FSD. Increasing age (beta = -0.187, P = 0.001), increasing systolic blood pressure (beta = -0.687, P < 0.001), and beta-blocker administration (beta = -0.162, P = 0.001) were significant predictors of sexual dysfunction in this patient population.

CONCLUSIONS

FSD is more prevalent in women with essential hypertension compared with women with normal blood pressure, and its prevalence declines with adequate blood pressure control. Adequate control of hypertension with medication not affecting sexual function can have a great impact on the quality of life of hypertensive patients. Physicians should recognize and properly manage FSD in hypertensive women.

The association of psychological stress and health related quality of life among patients with stroke and hypertension in Gaza Strip

BACKGROUND

The study was performed to investigate the association of psychological stress and quality of life (QOL) among patients with the cardiovascular disease (CVD) of hypertension plus stroke or hypertension only.

METHODS

The WHOQOL-BREF questionnaire was applied to 112 hypertensive patients with hypertension plus stroke and 224 hypertensive patients without stroke. Psychological stress was assessed with SCL-90. Means scale scores were compared using student-t-test and predictors of QOL were calculated with covariance analysis.

RESULTS

Patients with stroke had a significant lower QOL than patients without stroke and a significantly higher level of stress (p < 0.01). In analyses of covariance psychological stress was significantly correlated to all domains of QOL among non-stroke patients. The same psychological and sociodemographic factors showed little impact on the stroke patients in these multivariable analyses. In these models psychological stress had a significant impact on the global domain of QOL among stroke patients. Income and gender were the only sociodemographic factors being significantly associated with the physical (education) and social (gender) domains of QOL in stroke patients.

CONCLUSION

Psychological stress was strongly correlated with all domains of QOL in patients without stroke and was only partly associated with QOL among patients with stroke. Future studies should investigate if psychological stress is a factor suitable for educational and psychological interventions aiming at stress reduction in CVD patients which might substantially contribute to better health related quality of life in these patients.

Does hypertension and its pharmacotherapy affect the quality of sexual function in women?

Considerable research has been conducted into the effects of antihypertensive drugs on male sexual functioning. This remains underexplored in women, even though almost half of treated hypertensives are women. An ambulatory medical record-based, case-control study was designed to study sexual function in treated and untreated hypertensive women and healthy controls. We conducted this study at a teaching hospital with satellite clinics in upstate New York. Of 3312 medical records reviewed, 640 premenopausal white women with or without mild hypertension (defined as blood pressure [BP] > or = 140/90 and < 160/110 mmHg), in heterosexual relationships, with no other significant medical history, were eligible. Of these, 241 women agreed to participate, and 224 (35%) completed both a self-administered questionnaire and a telephone interview. Analysis was conducted on 211 women (107 healthy controls, and 104 mild hypertensives, of whom 37 were unmedicated and 67 medicated). Questions on sexuality were classified into seven composite variables and later further divided. There were no demographic differences between participants and nonparticipants. Cases and controls differed only by age (P < .01); therefore, subsequent analysis was age-adjusted. Current smokers reported a significantly lower mean score for orgasm than did nonsmokers (P = .04). Women with unmedicated and medicated hypertension did not differ significantly on sexuality scores and were subsequently combined. Using age-adjusted ANOVA, women with hypertension reported significantly decreased lubrication and orgasm and increased pain compared to nonhypertensive women. There were no significant differences by ANOVA in the quality of sexual functioning between six treatment groups. In conclusion, the quality of female sexual functioning was quantified in an ambulatory outpatient setting. Hypertensive women, regardless of type of treatment, reported age-adjusted decrease in vaginal lubrication, less frequent orgasm, and more frequent pain when compared to nonhypertensive women. Emotional aspects of sexual functioning in hypertensive women do not appear to be impaired. These areas require further investigation. An incidental finding indicated diminished orgasm reported in current smokers, compared to nonsmokers, which was not associated with age or hypertension.

Development of human and rabbit vaginal smooth muscle cell cultures: effects of vasoactive agents on intracellular levels of cyclic nucleotides

In this study, we subcultured and characterized human and rabbit vaginal smooth muscle cells and investigated the synthesis of second messenger cyclic nucleotides in response to vasodilators and determined the activity and kinetics of phosphodiesterase (PDE) type 5 (EC 3.1.4.35 3',5'-cyclic GMP phosphodiesterase). Cultured vaginal cells exhibited growth characteristics typical of smooth muscle cells and immunostained with antibodies against alpha smooth muscle actin. The cells retained functional prostaglandin E and beta-adrenergic receptors as demonstrated by increased intracellular cAMP synthesis in response to PGE1, or isoproterenol. The response to these vasoactive substances was augmented with forskolin, suggesting stabilization of G-protein-activated adenylyl cyclases. Treatment with the nitric oxide donor, sodium nitroprusside, in the presence of sildenafil, a PDE type 5 inhibitor, enhanced intracellular cGMP synthesis and accumulation. Incubation of rabbit vaginal tissue with sildenafil, sodium nitroprusside, and PGE1 or forskolin produced a marked increase in intracellular cGMP. These observations were similar to findings with cultured cells and suggest that subcultured cells retain functional characteristics exhibited in intact tissue. The cells retained phosphodiesterase type 5 expression as shown by specific cGMP hydrolytic activity. Sildenafil and zaprinast inhibited cGMP hydrolysis competitively and bound with high affinity (Ki = 7 and 250 nM, respectively). These observations suggest that cultured human and rabbit vaginal smooth muscle cells retained their metabolic functional integrity and this experimental system should prove useful in investigating the pathway of nitric oxide and PDE type 5 inhibitors in modulating vaginal smooth muscle tone.

Clinical pharmacokinetics of vasodilators. Part II

Stimulating cardiac beta 1-adrenoceptors with oxyfedrine causes dilatation of coronary vessels and positive inotropic effects on the myocardium. beta 1-adrenergic agonists increase coronary blood flow in nonstenotic and stenotic vessels. The main indication for the use of the phosphodiesterase inhibitors pamrinone, mirinone, enoximone and piroximone is acute treatment of severe congestive heart failure. Theophylline is indicated for the treatment of asthma, chronic obstructive pulmonary disease, apnea in preterm infants ans sleep apnea syndrome. Severe arterial occlusive disease associated with atherosclerosis can be beneficially affected by elcosanoids. These drugs must be administered parenterally and have a half-life of only a few minutes. Sublingual or buccal preparations of nitrates are the only prompt method (within 1 or 2 min) of terminating anginal pain, except for biting nifedipine capsules. The short half-life (about 2.5 min) of nitroglycerin (glyceryl trinitrate) makes long term therapy impossible. Tolerance is a problem encountered with longer-acting nitric oxide donors. Knowledge of the pharmacokinetic properties of vasodilating drugs can prevent a too sudden and severe blood pressure decrease in patients with chronic hypertension. In considering the administration of a second dose, or another drug, the time necessary for the initially administered drug to reach maximal efficacy should be taken into account. In hypertensive emergencies urapidil, sodium nitroprusside, nitroglycerin, hydralazine and phentolamine are the drugs of choice, with the addition of beta-blockers during catecholamine crisis or dissecting aortic aneurysm. Childhood hypertension is most often treated with angiotensin-converting enzyme (ACE) inhibitors or calcium antagonists, primarily nifedipine. Because of the teratogenic risk involved with ACE inhibitors, extreme caution must be exercised when prescribing for adolescent females. The propagation of health benefits to breast-fed infants, combined with more women delaying pregnancy until their fourth decade, has entailed an increase in the need for hypertension management during lactation. Low dose hydrochlorothiazide, propranolol, nifedipine and enalapril or captopril do not pose enough of a risk of preclude breastfeeding in this group. The most frequently used antihypertensive agents during pregnancy are methyldopa, labetalol and calcium channel antagonists. Methyldopa and beta-blockers are the drugs of choice for treating mild to moderate hypertension. Prazosin and hydralazine are used to treat moderate to severe hypertension and hydralazine, urapidil or labetalol are used to treat hypertensive emergencies. The use of overly aggressive antihypertensive therapy during pregnancy should be avoided so that adequate uteroplacental blood flow is maintained. Methyldopa is the only drug accepted for use during the first trimester of pregnancy.

Long-term effects on sexual function of five antihypertensive drugs and nutritional hygienic treatment in hypertensive men and women. Treatment of Mild Hypertension Study (TOMHS)

Problems with sexual function have been a long-standing concern in the treatment of hypertension and may influence the choice of treatment regimens and decisions to discontinue drugs. The Treatment of Mild Hypertension Study (TOMHS) provides an excellent opportunity for examination of sexual function and effects of treatment on sexual function in men and women with stage I diastolic hypertension because of the number of drug classes studied, the double-blind study design, and the long-term follow-up. TOMHS was a double-blind, randomized controlled trial of 902 hypertensive individuals (557 men, 345 women), aged 45 to 69 years, treated with placebo or one of five active drugs (acebutolol, amlodipine maleate, chlorthalidone, doxazosin maleate, or enalapril maleate). All participants received intensive lifestyle counseling regarding weight loss, dietary sodium reduction, alcohol reduction (for current drinkers), and increased physical activity. Sexual function was ascertained by physician interviews at baseline and annually during follow-up. At baseline, 14.4% of men and 4.9% of women reported a problems with sexual function. In men, 12.2% had problems obtaining and/or maintaining an erection; 2.0% of women reported a problem having an orgasm. Erection problems in men at baseline were positively related to age, systolic pressure, and previous antihypertensive drug use. The incidences of erection dysfunction during follow-up in men were 9.5% and 14.7% through 24 and 48 months, respectively, and were related to type of antihypertensive therapy. Participants randomized to chlorthalidone reported a significantly higher incidence of erection problems through 24 months than participants randomized to placebo (17.1% versus 8.1%, P = .025). Incidence rates through 48 months were more similar among treatment groups than at 24 months, with nonsignificant differences between the chlorthalidone and placebo groups. Incidence was lowest in the doxazosin group but was not significantly different from the placebo group. Incidence for acebutolol, amlodipine, and enalapril groups was similar to that in the placebo group. In many cases, erection dysfunction did not require withdrawal of medication. Disappearance of erection problems among men with problems at baseline was common in all groups but greatest in the doxazosin group. Incidence of reported sexual problems in women was low in all treatment groups. In conclusion, long-term incidence of erection problems in treated hypertensive men is relatively low but is higher with chlorthalidone treatment. Effects of erection dysfunction with chlorthalidone appear relatively early and are often tolerable, and new occurrences after 2 years are unlikely. The rate of reported sexual problems in hypertensive women is low and does not appear to differ by type of drug. Similar incidence rates of erection dysfunction in placebo and most active drug groups caution against routine attribution of erection problems to antihypertensive medication.

Characteristics and treatment of hypertension in women: a review of the literature

Although there are documented differences between women and men in frequency and severity of hypertension and in the relation between hypertension and cardiovascular risk, few studies have been designed to evaluate efficacy and safety of antihypertensive therapy in women. Efficacy of nonpharmacologic interventions to lower blood pressure may differ between the sexes; women have greater difficulty losing weight than men but may respond better than men to dietary sodium reduction. In general, women and men do not respond differently to antihypertensive therapy; however, there may be differences in response to certain classes of antihypertensives. There are limited data on safety of specific antihypertensive agents in women. In some studies, researchers found a greater incidence of adverse effects in women. Effects on sexual functioning and pharmacokinetic and pharmacodynamic characteristics of antihypertensive drugs in women have been studies inadequately. More data are needed to guide the management of hypertension in women.