Sexual dysfunction and the cardiac patient – no room for gender bias

In this issue (pp 445-451) we publish a Consensus Statement on erectile dysfunction (ED) and the male cardiovascular patient. We acknowledge the lack of data in women and the need for more research to determine if there is a significant problem and what we should do about it. Riley and co-workers 1 looked at the prevalence of sexual dysfunction (SD) in male and female hypertensive patients. One hundred and seventyeight women reported on their ability to become sexually aroused and to attain orgasm: 22% reported no difficulty becoming aroused, 57% sometimes experienced difficulty, 13% usually and 8% always. There were no age-related differences and no differences in whether they were treated or untreated. Twelve per cent of women never experienced an orgasm, 46% usually, 8% always and 34% sometimes. Again, there was no age-related difference or difference between treated and untreated women. Women had a significantly (p<0.0001) greater prevalence of arousal difficulties than men. In this population there was therefore a surprisingly high prevalence of SD in women, so much so that it would be difficult to differentiate between the treated and the untreated. However, the study suggests the problem is significantly greater than generally believed. In the Treatment of Mild Hypertension Study (TOMHS)2 there were 345 women. At baseline 4.9% reported SD, with 2.0% having problems attaining an orgasm. This low incidence of SD remained during the study with no obvious drug effects apart from a slightly higher rate of SD on amlodipine compared with acebutolol, chlorthalidone, doxazosin, enalapril and placebo. It is possible, as the authors concede, that the apparently low incidence of SD reflected the limited questionnaire and most of the study physicians being male. Overall, the study did not suggest that treating hypertension adversely affected sexual activity. In a study comparing propranolol ( a beta-blocker) with indoramin (an alpha-blocker) and placebo, nine female volunteers reported on arousal following exposure to an erotic video.3 Propranolol, but not indoramin, significantly reduced the level of sexual arousal. This could have been a central effect, as propranolol crosses the blood-brain barrier, rather than reflecting any specific beta-blocking property. Other centrally acting drugs, clonidine and methyldopa, are reported to impair female orgasm. Some drugs may impair vaginal lubrication (a problem not asked about in the TOHMS paper); these include labetalol, thiazides and spironolactone. • Other drugs may influence SD by primarily reducing libido, the commonest being phenothiazines, anxiolytics, antidepressants, endocrine drugs, recreational drugs ( e.g. alcohol, amphetamines, cocaine, anabolic steroids), cimetidine, ranitidine, metoclopramide and carbamazepine. In an overview of psychosocial factors of coronary disease in women,5 the authors concluded: 'Data on sexual activity of women after myocardial infarction or coronary artery bypass grafting are scarce, and there seems to be a complete lack of physician counselling in this topic. ' Small studies have suggested a reduction in sexual activity or no change but a lack of information and counselling appears to be common. " In a study of sexual activity triggering MI, the risk was low but too few women reported sexual activity in the.two hours preceding an MI to determine any gender differences. 7 An interesting study of ephedrine sulphate, an aand ~-adrenergic agonist, looked at subjective and physiological sexual arousal in 24 sexually active women. 8 Ephedrine significantly facilitated the physiological initial phases of sexual arousal but not the subjective ratings. One possibility that ephedrine may help women with SD clearly needs further evaluation but, more importantly, the door appears to have opened to other pharmacological avenues which may help women with SD. At the moment we are only just beginning to realise that women with a cardiovascular problem may experience SD. The evidence base does not allow us to provide guidelines based on prevalence and outcome we simply do not have enough information. Gender bias in cardiology has received a lot of attention in recent years; because a women's sexual problems are not as obvious as a man's, it does not mean they are not as important, and we must try to avoid any gender bias in dealing with them. We need to develop our cardiac rehabilitation programmes to provide information on sexual activity for women with cardiovascular disease ( and their partners), and we must audit their effectiveness. Women's sexual concerns are just as important as men's.