The Prevalence and Clinical Relevance of Sexual Dysfunction in Women and Men with Chronic Heart Failure

ORIGINAL ARTICLE The prevalence and clinical relevance of sexual dysfunction in women and men with chronic heart failure

ER Schwarz1,2, V Kapur2, S Bionat2, S Rastogi2, R Gupta2 and S Rosanio2

1Division of Cardiology, Department of Medicine, Cedars Sinai Medical Center and University of California Los Angeles (UCLA), Los Angeles, CA, USA and 2Division of Cardiology, Department of Internal Medicine, The University of Texas Medical Branch (UTMB), Galveston, TX, USA

Sexual dysfunction is a common problem of increasing incidence that is associated with multiple co-morbid conditions and chronic diseases. In heart failure, however, exact numbers are unknown, in part secondary to under-reporting and under-interrogating by health care providers. A gender- specific questionnaire was modified from established sexual dysfunction questionnaires to correspond to a non-randomized outpatient heart failure population, to assess the prevalence and demographic distribution of sexual dysfunction and potential treatments expectations. One- hundred patients in a stable hemodynamic condition in New York Heart Association classes I–III participated. Eighty-seven percent of women were diagnosed with female sexual dysfunction compared to 84% of men with erectile dysfunction. Eighty percent of women reported reduced lubrication, which resulted in frequent unsuccessful intercourse in 76%. Thirty-six percent of patients thought that sexual activity could harm their current cardiac condition; 75% of females and 60% of men stated that no physicians ever asked about potential sexual problems. Fifty-two percent of men considered sexual activity in their current condition as an essential aspect of quality of life and 61% were interested in treatment to improve sexual function. Sexual dysfunction appears to be high in prevalence in both men and women with chronic compensated heart failure and represents a reduction in quality of life for most. Despite the fact that most patients are interested in receiving therapy to improve sexual dysfunction, treatment options are rarely discussed or initiated. International Journal of Impotence Research (2008) 20, 85–91; doi:10.1038/sj.ijir.3901613; published online 20 September 2007

Keywords: heart failure; sexual dysfunction; erectile dysfunction

Introduction factors for the development of male ED.1,2 In particular, diabetes mellitus, hypertension, dyslipi- Heart failure is a highly prevalent and common demia and smoking are associated both with cardio- cardiovascular disorder. As with many other vascular disorders and male impotence. In addition, chronic diseases such as renal or liver failure, heart use of medications such as thiazide diuretics, failure is associated with a high prevalence of digoxin and, in part, b blockers are believed to erectile dysfunction (ED) in men. The exact num- worsen or sometimes even to cause sexual dysfunc- bers, however, are unknown, and data in women tion in men.3 Male ED is defined as the persistent with heart failure are lacking. Risk factors that are inability to achieve/maintain an erection sufficient common and contribute to the development of for satisfactory sexual performance.1 In the Massa- cardiovascular diseases such as coronary artery chussetts Male Aging study, 52% of men between disease, which might lead to ischemic cardiomyo- the ages of 40 and 70 years were suffering from some pathy and heart failure, are also considered as risk degree of ED.4 There is obviously a close relationship between cardiovascular diseases in general and ED caused by underlying endothelial dysfunction. Even more, ED might be considered as a potential Correspondence: Dr ER Schwarz, Division of Cardiology, Cedar Sinai Medical Center, 8700 Beverly Blvd, Suite risk factor for either the development or the coexis- 6215, Los Angeles, CA 90048, USA. tence of cardiovascular disorders. Despite the E-mail: [email protected] evidence, many health care providers do not pay Received 19 April 2007; revised 17 August 2007; accepted much attention to potential sexual problems. More- 17 August 2007; published online 20 September 2007 over, according to the second Princeton Consensus Sexual dysfunction in heart failure ER Schwarz et al 86 Conference guidelines, treatment of sexual dysfunc- institutional review board. The survey was con- tion in men should be deferred if patients are ducted from October 2003 to November 2005 in a considered at high risk,5 but these recommendations dedicated heart failure clinic setting. Only hemo- are not without controversy. The consequence is that dynamically stable patients, who are not on many men with underlying heart disease and inotropic support and not requiring hospital admis- concomitant ED are not treated for ED. Therefore, sion for acute decompensation, were enrolled. it is important for physicians to address sexual Patients were not randomized but prospectively concerns and potential treatment options in cardiac approached by a physician not involved in the patients. The present study was designed to shed patients’ usual care. The questionnaire was blinded light in the often under-reported prevalence of for analysis and no patient identifiers were available female and male sexual dysfunction in a distinct during analysis. All patients were given the option population of patients with compensated chronic to either take the questionnaire to their homes and heart failure. mail it back or to fill out the questionnaire in the clinic setting. Patients were encouraged to answer as many questions as possible to the best of their Methods knowledge. The completed questionnaire was then stored in separate envelopes in a secure location The protocol was approved by the institutional for further evaluation. All answers were analyzed. IRB. There was no outside funding for the study. In some questions with more than one possible Established questionnaires on sexual function answer, some responses were grouped together for and dysfunction were used to create a modified analysis. version of a gender-specific questionnaire directed towards patients with heart failure such as (1) the abridged International Index of Erectile Dysfunction Results (IIEF-5) questionnaire,6 (2) the Semi-structured 7 interview on erectile dysfunction questionnaire , A total of 105 patients were asked to participate (3) the quality of life questionnaire using the LiSat- in the study. Of those, five patients disagreed (one 8 ¼ Life Satisfaction questionnaire and the Index of 8 patient stated he did not want to participate, two Sexual Life questionnaire and (4) the Female patients stated that they were widows and had no Sexual Function Index for determination of female sexual partner since many years that was missed at sexual dysfunction (desire, arousal, lubrication, the initial inclusion visit, one male and one female orgasm, satisfaction, pain, total Female Sexual patients both had partners who were chronically Function Index, number of sexual intercourse/ very sick and therefore thought that their informa- month). Our modified version focused on three tion might not be valuable). One hundred patients aspects: patient’s sexual activity including any signs who stated that they were sexually active partici- and symptoms of sexual dysfunction, the patients pated in the questionnaire consisting of 76 males perception of potential causes and treatment desire (age 58718 years) and 24 females (age 59716 and options, and the patient’s evaluation of heath years). The frequency of sexual activities, with or care with regard to provide adequate solutions in without a partner, was not part of inclusion criteria case of problems. The questions were grouped or the presented study design. The patients’ demo- into the following clusters: (1) sexual desire/libido, graphics are given in Table 1. For unknown reasons, (2) sexual function, (3) orgasm, (4) overall sexual in few cases not all questions were answered satisfaction, (5) changes in sexual function over completely, that is there was either no reply or time, (6) perceptions and quality of life and (7) (in few questions) an answer option ‘not applicable’ expectations for treatment and the role of health care was checked, so that the data given here do not providers. necessarily always add up to 100% of responses. Adult patients were included if they fulfilled the following criteria: established diagnosis of heart failure (46 months), currently in New York Heart Association (NYHA) classes I–III, on medical management; ability to read and understand the Table 1 Baseline demographics of all heart failure patients study and the questions, willingness and informed Parameters Women Men All patients consent to participate in the study. Only patients who stated that they were either married or were N ¼ 24 76 100 currently in a stable relationship with a partner Age (x7s.d.) 58718 59716 59 and who stated that they are sexually active were Ischemic 12 (50%) 32 (43%) 44 enrolled. The frequency or kind of sexual activity Diabetes 12 (50%) 23 (31%) 35 Smokers 14 (61%) 29 (38%) 43 was not part of the inclusion or exclusion criteria, Hypertension 19 (83%) 63 (83%) 82 nor was the sexual orientation. There were no other Hyperlipidemia 9 (38%) 42 (56%) 51 exclusion criteria. The study was approved by the

International Journal of Impotence Research Sexual dysfunction in heart failure ER Schwarz et al 87 Sexual desire/libido Sexual dysfunction: ED vs. FSD∗ In all, 76% of males and 87% of females reported 100% 87% reduced sexual desire or arousal, defined as any 84% reduction in sexual desire in comparison to the 80% patients’ former functionality without sexual problems to either a severe degree (very low desire), a 70% moderate degree (low sexual desire) or any signifi- % Male cant reduction (modest or higher reduction in 60% % Female desire). Therefore, 87% of women with heart failure were diagnosed with female sexual arousal disorder 50% (Figure 1). 40%

30% Sexual function/erectile function Overall, 79% of men reported significantly reduced

Percentage of Respondents 20% number of erections sufficient for penetration. Thirty-one percent of men stated that they never 10% get an erection sufficient enough to penetrate; 84% of men reported problems in maintaining erections 0% after penetration, therefore fulfilling the clinical Figure 1 Bar graph showing the prevalence of sexual dysfunc- diagnosis of ED (Figure 1). Only 8% of men reported tion among women and men with chronic compensated heart not to have any problems in getting an erection failure. *ED (male erectile dysfunction) FSD (female sexual sufficient for sexual intercourse or to maintain an dysfunction) as analyzed from the questionnaire. erection until climax. Eighty percent of females reported decreased lubrication before and during stimulation and initially during sexual intercourse in at least more than half of attempts compared to Overall, 68% of men and 50% of women recalled conditions prior to the onset of heart failure. Fifty that sexual problems occurred prior to the onset percent of women reported a further decrease in of symptoms of heart failure or before a diagnosis lubrication during intercourse that in some even of heart failure was established. resulted in moderate to severe pain. A history of recurrent unsuccessful or interrupted intercourses because of the above reasons was reported in 76% of Perceptions and quality of life issues women. Despite the fact that many patients admitted that sexual activity has become less important since the onset of heart failure symptoms, 52% of males and Orgasm 38% of females stated that sex currently played an Seventy-three percent of men reported difficulties important role in their life. Overall, 62% of men and with orgasm (which was defined as either no orgasm 45% of women claimed that their partners were or premature orgasm). Sixty-two percent of women understanding and supportive with regard to their reported not being able to have an orgasm either in sexual problems whereas 4% of men and 21% of most (more than half of) attempts. Only 9% of women stated that their lifetime partner reacted women reported that they never had any difficulties non-supportive (‘being mad at me’) because of the to achieve an orgasm during sexual activity. patient’s sexual problems (Figure 2). In addition, 13% of male partners and 8% female partners seemed to avoid talking about their partner’s sexual Satisfaction problems with their partner. Interestingly, more men Overall, 80% of men and 83% of women stated not than women (59 versus 31%) thought that sexual to be satisfied with their current sexual activities dysfunction was solely a consequence of the aging and their ability to have successful intercourse. process and 40% of men and 25% of women believed that sexual activity could be in fact harmful Changes over time to their present cardiac condition. In all, 50% of men and 67% of women reported no change in their sexual activity or their global cardiac and health symptoms within the last 6 months, Role of health care providers and expectations whereas 43% of men and 29% of women reported for treatment a steady decline in sexual function within the last Overall, 68% of males and 50% of females believed 6 months. Most of the patients believed that a that there are treatment options that could be applied worsening heart condition and increasing age was for their individual case to improve sexual dysfunc- the cause of their worsened sexual functionality. tion. None of the women but 36% of men had tried

International Journal of Impotence Research Sexual dysfunction in heart failure ER Schwarz et al 88 How does your partner How many physicians that have participated in your respond to your sexual problem? health care (within the last three years) have asked you about possible sexual problems? 70% % Male 62% 80% 75% 60% % Female % Male 70% % Female 50% 45% 60% 60% 40% 50% 30% 40%

20% 30% 20% 10%

Percentage of Respondents Percentage 10%

0% of Respondents Percentage Supportive Non-supp. Mad at me/ Avoids talking 0% left about it None One approx.50% 100% Figure 2 Percentage of responses to the question; how the life Figure 3 Responses to the question; how many physicians (who partner reacts toward the sexual problems within the partnership. were part of regular health care) have asked the patients about Non-supp., non-supportive. potential sexual problems within the last 3 years. Included are primary care physicians, internists, cardiologists among other specialists (except dentists).

some kind of (over-the-counter or over-the-internet) medication to self-medicate their sexual problems. Do you want to be treated to Most men (58%) had seen at least three physicians improve your sexual function? within the last 3 years for health related issues 70% and most women (58%) had seen between 4 and 61% % Male 10 physicians within the last 3-year period. Sixty 60% % Female percent of men and 75% of the women recalled that none of the physicians consulted within the last 50% 3 years had ever inquired about possible sexual problems (Figure 3). In contrast, most patients (61% 40% 38% of men and 38% of women, respectively) felt an urge to discuss these issues with their health care 30% providers and were interested in receiving treatment to improve sexual dysfunction (Figure 4). 20%

Percentage of Respondents Percentage 10%

Discussion 0% Ye s The main findings of our questionnaire are as Figure 4 Responses from male and female heart failure patients follows: (1) Eighty-four percent of men with chronic whether they are interested in treatment to improve their current but compensated heart failure in NYHA classes I–III sexual dysfunction. fulfilled criteria for ED. (2) Eighty-seven percent of women with chronic compensated heart failure fulfilled criteria for female sexual arousal disorder, ejection fraction or ‘heart failure’. (4) Interestingly, as derived from a self-assessment questionnaire. 68% of males and 50% of females believed in Furthermore, 52% of men and at least 38% of possible successful treatment options. Unfortu- women admitted that sex is important and that nately, the majority of physicians who were invol- sexual problems reduce their quality of life at the ved in the medial care within the last 3 years did not present time. (3) A large percentage of patients (68% actively interrogate about possible sexual problems males and 50% females) reported that their sexual in this patient cohort. problems occurred prior to the onset of heart failure symptoms and worsened over time. In contrast, it cannot be verified from our questionnaire if this Sexual dysfunction in general was really the case or if some degree of cardiac Erectile dysfunction is a commonly under-diagnosed dysfunction was present before the onset of sexual disease entity that shares common risk factors and dysfunction, since in many cases there was some pathophysiologic mechanisms with cardiovascular controversy with regard to the patients’ history disease,9 affecting approximately 30 million men and the exact onset of symptoms versus the first in the United States.10,11 One of the early studies to diagnosis of either systolic dysfunction, a reduced assess the prevalence of sexual dysfunction was

International Journal of Impotence Research Sexual dysfunction in heart failure ER Schwarz et al 89 published by Kinsey in 1948. He showed that 25% According to the American Foundation of Urolo- of men above the age of 65 years and 80% of men gic Disease Consensus Panel, female sexual dysfunc- above 80 years suffered from some degree of sexual tion is now often subdivided as lifelong versus dysfunction.12 More recently, Feldman et al.4 repor- acquired, generalized versus situational and organic ted the prevalence of impotence in a general popu- versus psychogenic or mixed and encompasses lation using data from the Massachusetts Male several distinct disorders such as hypoactive sexual Aging Study. The authors showed that 52% of men desire disorder, sexual aversion disorder, sexual exhibited sexual dysfunction, with 39% of men at arousal disorder, orgasmic disorder, sexual pain 40 years of age and 67% among those 70 years or disorders such as dyspareunia, vaginismus or other older. sexual pain disorders.19 In our study, 84% of males and 87% of females with heart failure reported some degree of sexual Sexual dysfunction and heart failure dysfunction, close to data from Westlake who repor- In contrast to data in the general population and the ted a significant decrease in sexual function and association between cardiovascular disease and ED, frequency of sexual relations in 75% of patients only little data exist in the heart failure population. with advanced heart failure.20 These numbers are Jaarsma et al.13 studied 73 patients with heart failure comparable to findings by Kloner et al.21, who esti- (mean age 70 years) and showed that in 80% of the mated a 75% prevalence of ED in men with coronary men heart failure affected sexual function and artery disease. In a recently published paper by relationships. Our questionnaire was conducted on Hayes et al.22, 64% of (healthy) females experienced a non-selected group of outpatients in stable condi- desire difficulty and up to 64% experienced arousal tion (without any kind of ‘recovery’ after a recent difficulties, compared to 78 and 87% of women event), which represent more a general population with heart failure in our cohort. In a study assessing with an established diagnosis. Despite a relative female sexual dysfunction in Turkey, it was shown good functional capacity in this cohort (all patients that there were problems with desire in 48%, with were in NYHA classes I–III), the prevalence of arousal in 36% and with pain in 43% of the sexual dysfunction is much higher than it could women.23 be explained by reduced cardiac capacity alone. Due to our questionnaire data 79% of males had As reviewed in detail previously3 other factors than reduced number of erections sufficient for erection just a reduction in cardiac performance seem to with 84% complaining of difficulties maintaining play a role. Endothelial dysfunction,9 medication erection after penetration. This number is higher side effects14,15 and psychologic aspects such as than previously reported data in men with coronary depression and isolation16 might all contribute to artery disease showing that 67% of men had diffi- the development of sexual dysfunction in patients culties maintaining erections sufficient for success- with chronic heart failure. ful intercourse.20 A survey of 106 men above 16 years of age in the United Kingdom demonstrated that 32% had difficulties achieving erections and Female sexual dysfunction 20% had difficulties maintaining erections during Not surprisingly, there is even less data available intercourse,13 but, of note, these individuals were on female sexual dysfunction. In 1999, Laumann not heart failure patients. et al.11 reported the prevalence of sexual dysfunc- Interestingly, 73% of our male patients and 62% tion in women. Twenty-seven percent of women of our female patients reported difficulties achieving aged 50–59 reported lack of interest in sexual an orgasm. In contrast, the National Health and activity, and 23% of women were not able to achieve Social Life Survey and other data showed that 15% an orgasm. In addition, 27% of women reported of males and 23% of females between 50 and 59 insufficient lubrication, and a small number of years of age were unable to achieve orgasm.24 It was participants (6%) reported anxiety regarding and unclear, however, independent of ED, if and why in response to sexual performance. Sidi et al.17 orgastic capacity seems to be impaired in patients reported sexual dysfunction in 30% of 230 Malay- with heart failure,25 but reduced cardiac capacity sian women (age 18–70 years), and, in addition, low as well as neurohormonal regulatory mechanism sexual arousal, lack of lubrication, sexual dissatis- might contribute to these findings. faction or sexual pain in more than 52%. About 68% of men and 50% of women stated that On the basis of the National Health and Social their sexual problems occurred prior to the clinical Life Survey of 1749 women, 43% have complaints onset of heart failure, confirming data previously of sexual dysfunction, but older women were not published (67% of patients reported clinically appa- included in that particular trial.18 There is some rent sexual dysfunction symptoms prior to onset of evidence that disease processes and risk factors that cardiovascular disease symptoms26). are associated with male ED are also associated with Many patients were interested to discuss sexual female sexual dysfunction, indicating a possible problems with their physicians, men more than common pathophysiologic mechanism.19 women (61 versus 38%), which is comparable to

International Journal of Impotence Research Sexual dysfunction in heart failure ER Schwarz et al 90 40% of patients by Dunn et al.27 Reasons for the not include a non-heart failure population as a gender difference could be that men might be more control group; therefore, a selection bias within affected by loss of sexual function than women28 a particular group or region cannot be completely and men might have more confidence in successful ruled out. Also, the patient’s complaints about treatment secondary to the marketing efforts and possible sexual dysfunction and the data given clinical success data of PDE-5 inhibitors for treat- here were derived from a questionnaire that was ment of ED while treatment for female sexual designed to address this specific patient popu- dysfunction is in its earliest stages. Surprisingly, lation and, thus, represents a modification of well- our data reveal that most patients were never asked established standard questionnaires (such as the by their physicians within a 3-year period about International Index of Erectile Dysfunction (IIEF-5)). possible sexual problems, which created general The answers, however, were not clinically verified disappointment in health care with regard to by further (urologic, gynecologic or psychiatric) concerns regarding sexual dysfunction among both investigations. Therefore, the study is purely des- men and women. However, since this is a single criptive but not analytic, and thus, might raise more center study, we cannot rule out a selection bias due questions than provide answers. to a specific geographic and cultural region, and our data might not be representative for other areas. Altogether, our data show a high rate of sexual Conclusions dysfunction in both men and women with chronic compensated heart failure. The causes are multi- Heart failure appears to be closely associated with factorial: (1) risk factors that might lead to coronary sexual dysfunction in both men and women. Special artery disease and heart disease also have been attention and awareness among health care provi- associated with ED in men, but also with sexual ders is required to provide dedicated diagnostic dysfunction in women; (2) endothelial dysfunction approaches and treatment. has been considered as one of the main common denominators for (male) ED and seems to be prevalent in heart failure patients, even independent of Acknowledgments the etiology; (3) medication side effects are potential causes for worsening sexual function; (4) reduced There was no funding for the study. The authors cardiac capacity and reduced conditioning second- have no conflict of interest. ary to reduced left ventricular function are considered additional contributing factors. 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Appendix

NYHA classification: New York Heart Association heart failure functional classification system, classes I–IV

NYHA functional classes are I (asymptomatic), II (symptomatic with ordinary activity), III (symptomatic with less than ordinary activity) and IV (symptomatic at rest).

International Journal of Impotence Research