Many people with CVD and HF experience sexual problems related to their cardiac disease, medications, fatigue, depression and stress. While a change in sexual activity or function may have a major impact on quality of life, it is rarely discussed in a clinical setting as the clinician or the patient may not feel comfortable talking about sexual issues and therefore it may be trivialised or ignored. [#levine-gn-steinke-ee-bakaeen-fg-et-al.-2012] It is therefore important to encourage patients to discuss with a member of the treating team any concerns they may have about their sexual function or libido.
How do I talk about sex with a patient?
Assessment of sexual concerns is of significant importance to individuals with cardiac conditions and is often rated as being poorly considered by clinicians. [#medina-m-walker-c-steinke-e-et-al.-2009]
Sometimes just mentioning the possibility of sexual issues may enable the patient to bring it up with you or another health provider when they are ready. If issues require more than basic information it is advisable to refer the patient to a GP or sexual counsellor.
Tips for broaching the subject of sexual functioning
- Bring up the topic of sexual activity within the context of activities of daily living such as driving and working.
- Normalise and generalise. Make a statement followed by an open ended question. For example:
“Following a heart attack/ cardiomyopathy/ open heart surgery many men are worried about resuming sexual activity. What worries have you had?”
“It’s normal after a transplant for men to notice loss of interest in sex or performance problem. What changes have you noticed?" [#king-r.-2014]
- Gain permission. In certain circumstances such as when using an interpreter, or where there are cultural sensitivities, gain the patient's permission by saying "Is sexual activity something that you would like me to talk about?"
There is potential for patients and clinicians to believe that erectile dysfunction is solely related to medications, however other contributors should be considered such as acute stress, pre-morbid erectile function, age and levels of anxiety or depression. Erectile dysfunction related to, or perceived to be related to, medication may cause the patient to consider stopping the medication.
Male patients who experience erectile dysfunction should be supported and encouraged to discuss this with their doctor as drugs or other aids may improve their erectile function. Phosphodiesterase (PDE) inhibitors (PDE5 selective inhibitors include Viagra® (sildenafil), Cialis® (tadalafil) and Levitra® (vardenafil)), maybe prescribed for patients provided that they are not receiving nitrate therapy and are not experiencing hypotension, arrhythmias or angina.
Loss of sex drive is a common problem and is usually temporary. Emotional stress, depression, diabetes and many cardiac medications can affect sex drive. Patients with ongoing problems may benefit from specialised sexual counselling.
When to resume sexual activity
The risks for triggering a cardiac event during sexual activity are very low in a person who can exercise expending energy of 3-5 METS (going up 2 flights of stairs) without angina, hypotension, arrhythmia and ischemia. Those who experience symptoms of breathlessness or chest discomfort during or after sexual intercourse should consult their doctor.
The American Heart Association1 recommends that patients diagnosed with CVD receive a comprehensive evaluation from their healthcare provider before resuming sexual activity.
Advice for specific conditions:
- Sternotomy: Sexual activity can be resumed in line with hospital recommendations or at approximately 6-8 weeks provided the wound is well healed
- MI: Sexual activity is usually safe 2 or more weeks after a heart attack if there are no symptoms during mild to moderate activity
- PCI: Sexual activity is permitted after PCI if the vascular access site is without complications
- Device implantation (e.g. permanent pacemaker, defibrillator): During incision healing avoid supporting weight through arms during sexual activity, while considering the specific instructions about movement of the affected side given by the hospital
- HF: Usually there are no limitations on sexual activity except in advanced cases
- There is a correlation with sexual capacity and functional status ( NYHA class or 6 minute walk test) but not with ejection fraction [#levine-gn-steinke-ee-bakaeen-fg-et-al.-2012]
The American Heart Association recommends that sexual activity is likely to be safe in patients with NYHA class I or II HF
- For more advanced HF, it is recommended that patients are stabilised and receiving optimal treatment before engaging in sexual activity.
- Further information on sex and heart failure for patients is available from the www.heartfailurematters website.
- Women with CVD or HF should be advised about appropriateness of contraception methods and the safety of future pregnancies. Further information is available in the Pregnancy and Cardiomyopathy patient booklet
How to resume sexual activity
The following tips will guide patients on ways to re-introduce sex gently or to conduct ongoing sexual activity where there is advanced cardiac disease such as HF:
- Choose a time for sex when rested, relaxed and not pressured
- Avoid having sex immediately after eating a heavy meal or drinking excessive amounts of alcohol
- Have sex in a comfortable, familiar room that is not too hot or too cold and where you will not be interrupted
- Use foreplay as a warm-up period to help the body get used to the increased activity level of intercourse
- Have sex in less strenuous positions such as lying on the bottom or with you and your partner lying side by side
- Stop and rest if there is discomfort, breathlessness or fatigue during intercourse
Regular exercise reduces the risk of a sexual triggered cardiac event and may improve erectile dysfunction and therefore should be considered integral in the program to re-introduce sexual activity. [#levine-gn-steinke-ee-bakaeen-fg-et-al.-2012]
Some patients may benefit from a referral to a GP with an interest in sexual counselling.
Steinke et al. [#steinke-ee-jaarsma-t-barnason-sa-et-al.-2013] suggest that sexual counselling for all patients with CVD should include the following:
- Review of potential effects of medications on sexual function
- Risks related to sexual activity
- The role of regular exercise in supporting intimacy
- Use of a comfortable familiar setting to minimize any stress with sexual activity
- Use of sexual activities that require less energy expenditure as a bridge to sexual intercourse
- Reporting of warning signs experienced with sexual activity