Sexual Function in Women with Coronary Artery Disease: a Preliminary Study

ORIGINAL ARTICLE Sexual function in women with coronary artery disease: a preliminary study

C Kaya1, G Yilmaz1, Z Nurkalem2, A Ilktac1 and MI Karaman1

1Department of Urology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey and 2Cardiology Department, Siyami Ersek Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey

We investigated sexual function in female patients with coronary artery disease (CAD). A total of 20 consecutive female patients (38.273.8 years) with CAD diagnosed by coronary angiography and 15 healthy subjects (37.975.4 years) were enrolled in this study. The Female Sexual Function Index (FSFI) was used to assess sexual function in all the participants. Women with psychiatric disorders, gynecologic and systemic diseases that may affect sexual function were excluded from the study. The other exclusion criteria were usage of antidepressants and drugs affecting sexual function. Patients with CAD and healthy women were comparable in age, body mass index and education level. Female sexual dysfunction (FSD) was diagnosed in 12 of 20 women with CAD (60%), whereas five of 15 healthy women (33.3%) were found to have FSD (Po0.05). Patients with CAD had a significantly lower number of sexual intercourse episodes per month than healthy women volunteers (2.24 versus 5.2, respectively; Po0.05). The FSFI total score was clearly significantly decreased in the CAD group compared with that in healthy controls (17.872.9 and 26.074.8, P ¼ 0.001). When the subscores of each domain of FSFI were evaluated, all the subscores of FSFI, except the satisfaction domain, in patients with CAD were significantly lower than those of healthy subjects (Po0.05). This preliminary study demonstrates that female patients with CAD have distinct sexual dysfunction compared with healthy controls. Women with CAD should be evaluated also in terms of sexual function to provide better quality of life. International Journal of Impotence Research (2007) 19, 326–329. doi:10.1038/sj.ijir.3901530; published online 14 December 2006

Keywords: female; sexual function; coronary heart disease; vascular

Introduction recommended that the diagnosis and treatment of SD should be included in the clinical assessment of Sexual function is a complex process coordinated by patients with chronic diseases.6 the neurological, vascular and endocrine systems.1 Despite the high prevalence of FSD, little atten- Female sexual dysfunction (FSD) is age related, tion has been paid to the sexual problems of women. progressive and highly prevalent, affecting 22–76% In contrast, there has been widespread interest in of women according to age group.2–5 It has also been the research and treatment of male erectile dysfunc- shown that sexual dysfunction (SD) was more tion (ED). Fortunately, understanding the pathophy- prevalent among women (43%) than men (31%). siology and the treatment modalities of male ED has FSD has a major impact on quality of life and resulted in studies geared to better understand and interpersonal relationships. For many women, it has treat female sexual problems.4 been physically disconcerting, emotionally distres- It is now widely accepted that ED in a substantial sing and socially disruptive. Women with FSD were majority of men is due to underlying vascular found to have poorer quality of life, and it was causes, especially atherosclerosis.7 Montorsi et al. 8 have shown that almost 50% of men with coronary artery disease (CAD) have ED, and 67% of men with CAD and ED reported ED symptoms that began Correspondence: Dr C Kaya, Department of Urology, before CAD symptoms. Recent studies including our Haydarpasa Numune Training and Research Hospital, Bulgurlu mah. Uygarkent sit, A4 blok D17 Uskudar, previous paper concluded that ED and vascular disease may be linked at the level of the endothe- Istanbul 81190, Turkey. 9,10 E-mail: [email protected] lium. Heightened interest and research studies in Received 11 July 2006; revised 11 October 2006; accepted FSD have also brought new insight into cardiovas- 12 October 2006; published online 14 December 2006 cular changes. In addition, this research provides Sexual dysfunction in women with coronary artery disease C Kaya et al 327 a better understanding of the endocrinological, neuro- may affect sexual function were excluded from the logical and genital changes in women with regard to study. The other exclusion criteria were diabetes, their sexual response. uncontrolled hypertension and smoking in the last 3 To our knowledge, there are very few studies months in addition to the usage of antidepressants related to sexual function assessment in women and drugs affecting sexual function. with CAD. Therefore, we investigated sexual func- Values were expressed as mean þ s.d. and data tion in women with demonstrated CAD. comparing the FSFI scores of patients with CAD to those of age-matched control group were analyzed using Mann–Whitney U-test. P-value less than 0.05 was considered significant. Calculations were made Subjects and methods using SPSS software (SPSS, Chicago, IL, USA).

Between June 2005 and February 2006, a total of 20 consecutive, sexually active, heterosexual women Results with a mean age of 38.273.8 years (range of 32–47) with CAD demonstrated by coronary angiography Baseline demographics such as age, occupation, and 15 years age-matched, sexually active hetero- marital status, body mass index, fasting glucose and sexual healthy volunteer women without any lipid levels as well as serum hormone profile were cardiac symptoms from the female hospital staff similar in patients with CAD and healthy women (37.975.4 years; 28–46 years) were enrolled to (P40.05) (Table 1). There is no statistical difference participate in this investigation. The patients under- between patients and healthy volunteers in case of went dipyridamole myocardial contrast echocardio- usage of oral contraceptive drugs (12 in patients graphy (MCE) owing to stable angina pectoris, and with CAD, 10 in healthy women; P40.05) and the in patients with myocardial perfusion defects, the average number of children of women in both anatomy of coronary vessels was analyzed by groups (1.3 versus 1.2, respectively; P40.05). selective coronary angiography. In patients with Of the patients with CAD, six (30%) patients had significant coronary artery stenosis, the presence of hypertension as a risk factor. Coronary angiography 470% diameter narrowing of a coronary artery were results showed that nine (45%) had one-vessel included in the study. Severity of angina was disease, six (30%) had two-vessel disease and five estimated by Canadian Cardiovascular Society (25%) had three-vessel disease. The average number (CCS) classification of angina. All patients had of diseased vessel was found to be 1.8. CCS angina class 3 or 4. Healthy women as control Patients with CAD had a significantly lower group did not undergo coronary angiography to number of sexual intercourse episodes per month exclude any CAD. Patients and control women were than healthy women volunteers (2.24 versus 5.2, recruited into the study after an informed consent respectively; P 0.05). FSD was diagnosed in 12 of was signed. o 20 women with CAD (60%), whereas five of 15 All the participants were evaluated by medical healthy women (33.3%) were found to have FSD and sexual history. After a detailed physical exam- according to the FSFI score cutoff value of 25 ination, sexual function in these women was (P 0.05).11 The average FSFI total score was clearly determined by the Female Sexual Function Index o significantly lower in the CAD group (17.872.9) (FSFI), which was previously validated in the than in healthy controls (26.074.8) (P ¼ 0.001). Turkish language.11 The questionnaire, assessing When the scores of each domain of FSFI were sexual functioning with 19 questions, consists of evaluated, all the domain scores of FSFI, except the six sexual domains; sexual desire (questions 1 and satisfaction domain, were significantly lower in the 2), arousal (questions 3–6), lubrication (questions CAD group than those of healthy subjects (P 0.05). 7–10), orgasm (questions 11–13), satisfaction (ques- o The domain scores for desire (P ¼ 0.01), arousal tions 14–16) and degree of pain (questions 17–19) (P ¼ 0.004), lubrication (P ¼ 0.001), orgasm during intercourse.12 For each six domains, a score (P ¼ 0.000) and pain (P ¼ 0.05) were found to be is calculated and the total score is obtained by statistically significantly decreased in women with adding the six domain scores. The total score range CAD. The most affected domains were orgasm and is 2–36. A total score of 425 is considered normal lubrication. Although the satisfaction score was female sexual function and a total score 25 is o lower in patients with CAD, this difference was considered SD.11 not found to be statistically significant (Table 2). Blood was obtained to determine glucose, prolactin, luteinizing hormone (LH), dehydroepiandroster- one-SO (DHEA-SO), free testosterone (T), estradiol (E) and lipid profile in the follicular phase before Discussion 1000 h. Women with psychiatric disorders including Although FSD has a major impact on quality of life depression, gynecologic and systemic diseases that and interpersonal relationships, it has been less

International Journal of Impotence Research Sexual dysfunction in women with coronary artery disease C Kaya et al 328 Table 1 Demographic data on the participants

Variable CAD group (n ¼ 20) Control (n ¼ 15) P-value

Age, years 38.273.8 37.975.4 NS Body mass index (kg/m2)27742674NS

Education level Literate 3 2 NS Primary school 5 3 NS Middle school 5 3 NS High school 5 4 NS University 2 3 NS

FSFI score 17.872.9 26.074.8 o0.001 Plasma glucose level (mg/dl) 103718 97712 NS Total cholesterol (mg/dl) 199734 195721 NS Triglyceride (mg/dl) 160769 190794 NS Estradiol (E2) (pg/ml) 9.173.1 22.372.9 NS Free testosterone (pg/ml) 68737074NS LH (mIU/ml) 127716 123714 NS Prolactin (PRL) (ng/ml) 72710 7079NS Number of sexual intercourse episodes per month 2.2471.1 5.271.6 o0.001

Abbreviations: FSFI, Female Sexual Function Index; LH, luteinizing hormone; NS, nonsignificant; PRL, Prolactin.

Table 2 FSFI questionnaire scores of women with CAD and all domains except satisfaction. The average total healthy women FSFI score was also significantly lower in the CAD group than in healthy controls. Score CAD Control group P-value Several studies, researching the sexual function in women with chronic diseases, have reported that No. participants 20 15 Desire 2.1 þ 1.0 3.5 þ 0.8 0.01 about 25% of healthy control women were found 16 Arousal 2.4 þ 0.9 4.0 þ 0.8 0.004 to have FSD. In our study, 33% of healthy subjects Lubrication 3.3 þ 0.8 4.8 þ 0.6 0.001 had FSD, and this ratio was found to be comparable Orgasm 2.7 þ 0.7 4.4 þ 0.8 0.000 to the literature. Studies assessing FSD in cardiac Satisfaction 3.9 þ 0.5 4.5 þ 1.0 0.93 17 Pain 3.4 þ 0.7 4.5 þ 1.1 0.05 patients are very rare. Tessier et al. investigated Total FSFI 17.8 þ 2.9 26 þ 4.8 0.001 the sexual function in women after elective aortic surgery and revealed that it is maintained in women Abbreviations: CAD, coronary artery disease; FSFI, Female Sexual undergoing open reconstructive aortic surgery. They Function Index. found that women with occlusive disease tend to have poorer preoperative sexual function than aneurysm patients. Because of the association investigated than male ED. In recent years, some between SD and cardiovascular disease in both progress has been made in this field owing to sexes, in addition to the potential cardiac risk of heightened interest.13 the sexual activity itself, a consensus panel devel- Evidence-based data indicated that ED is extre- oped some recommendations for the clinical mely common in men with CAD,14 so that patients management of SD in patients with cardiovascular with CAD or risk factors should be asked about disease. The panel concluded that patients should sexual health and ED. It was hypothesized that be stabilized by specific treatment for their cardiac organic FSD may be related in part to vasculogenic condition before resuming sexual activity or being impairment of the hypogastric-vaginal/clitoral arter- treated for SD.18 In a study examining the preva- ial bed. The animal model of vaginal engorgement lence and correlates of sexual activity and function insufficiency showed that vaginal engorgement and in post-menopausal women with heart disease,19 clitoral erection depend on increased blood in- 65% of women reported at least one of five sexual flow.15 To our knowledge, there are no studies about function problems. They recommended that physi- the status of the sexual function of women with CAD cians should be aware that post-menopausal women in the literature. Therefore, we chose to investigate are sexually active and address the problems they the sexual function of patients with documented experience. Endothelial dysfunction appears to be CAD by angiography. The data in our study revealed a common pathological etiology and mechanism that FSD is more common in women with CAD of disease progression between CAD and ED, both (60%) than in healthy women (33%). All FSFI sharing mutual vascular risk factors. Also, it is questionnaire domain scores were found to be demonstrated that ED is an early symptom or affected with statistically significant differences in harbinger of cardiovascular disease, owing to the

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