Cardiovascular disease and female sexual health across the life span: a bidirectional link

Epidemiological research reveals that around 40 % of women aged 18-59 report significant concerns about their sexual experiences. Endothelial function and proper arterial blood flow through the hypogastric and pudendal arteries are critical in women for a normal vasculogenic response to sexual stimulation. Organic causes of female sexual dysfunction (FSD) often stem from neuropathy or vascular complications linked to cardiovascular risk factors. The relationship between cardiovascular disease (CVD) and FSD is multifactorial, influenced by various factors such as disease severity, physical and physiological factors, social determinants and factors related to medication use. Additionally, the pathophysiological mechanisms implicated in FSD of CVD patients include vascular, physical, psychological and hormonal factors. Hypertension, stroke, and myocardial infarction are closely interrelated with FSD, which is not the case for coronary heart disease, dyslipidemia, and peripheral obstructive artery disease. Hormonal treatment for sexual dysfunction in women with cardiovascular risk factors is discussed, concerning menopausal hormone therapy, tibolone, selective estrogen receptor modulators, vaginal estrogen, prasterone and testosterone therapy. On the other hand, the beneficial effect of sexual activity on cardiovascular health has been gaining supportive evidence. In healthy postmenopausal women aged 45-60, penile-vaginal intercourse has been suggested to positively influence cardiac autonomic functions, as indicated by heart rate variability. However, effectively addressing the challenges of aging and further highlighting the positive impact of sexual activity on cardiac health in selected female populations could significantly enhance life motivation and promote a healthy lifestyle during this stage. The present review elucidates the bidirectional relationship between CVD and female sexual function.

Sexual counselling for sexual problems in patients with cardiovascular disease

BACKGROUND

Sexual problems are common among people with cardiovascular disease. Although clinical guidelines recommend sexual counselling for patients and their partners, there is little evidence on its effectiveness.

OBJECTIVES

To evaluate the effectiveness of sexual counselling interventions (in comparison to usual care) on sexuality-related outcomes in patients with cardiovascular disease and their partners.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, and three other databases up to 2 March 2015 and two trials registers up to 3 February 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs, including individual and cluster RCTs. We included studies that compared any intervention to counsel adult cardiac patients about sexual problems with usual care.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included three trials with 381 participants. We were unable to pool the data from the included studies due to the differences in interventions used; therefore we synthesised the trial findings narratively.Two trials were conducted in the USA and one was undertaken in Israel. All trials included participants who were admitted to hospital with myocardial infarction (MI), and one trial also included participants who had undergone coronary artery bypass grafting. All trials followed up participants for a minimum of three months post-intervention; the longest follow-up timepoint was five months.One trial (N = 92) tested an intensive (total five hours) psychotherapeutic sexual counselling intervention delivered by a sexual therapist. One trial (N = 115) used a 15-minute educational video plus written material on resuming sexual activity following a MI. One trial (N = 174) tested the addition of a component that focused on resumption of sexual activity following a MI within a hospital cardiac rehabilitation programme.The quality of the evidence for all outcomes was very low.None of the included studies reported any outcomes from partners.Two trials reported sexual function. One trial compared intervention and control groups on 12 separate sexual function subscales and used a repeated measures analysis of variance (ANOVA) test. They reported statistically significant differences in favour of the intervention. One trial compared intervention and control groups using a repeated measures analysis of covariance (ANCOVA), and concluded: "There were no significant differences between the two groups [for sexual function] at any of the time points".Two trials reported sexual satisfaction. In one trial, the authors compared sexual satisfaction between intervention and control and used a repeated measured ANOVA; they reported "differences were reported in favour of the intervention". One trial compared intervention and control with a repeated measures ANCOVA and reported: "There were no significant differences between the two groups [for sexual satisfaction] at any of the timepoints".All three included trials reported the number of patients returning to sexual activity following MI. One trial found some evidence of an effect of sexual counselling on reported rate of return to sexual activity (yes/no) at four months after completion of the intervention (relative risk (RR) 1.71, 95% confidence interval (CI) 1.26 to 2.32; one trial, 92 participants, very low quality of evidence). Two trials found no evidence of an effect of sexual counselling on rate of return to sexual activity at 12 week (RR 1.01, 95% CI 0.94 to 1.09; one trial, 127 participants, very low quality of evidence) and three month follow-up (RR 0.98, 95% CI 0.88 to 1.10; one trial, 115 participants, very low quality of evidence).Two trials reported psychological well-being. In one trial, no scores were reported, but the trial authors stated: "No treatment effects were observed on state anxiety as measured in three points in time". In the other trial no scores were reported but, based on results of a repeated measures ANCOVA to compare intervention and control groups, the trial authors stated: "The experimental group had significantly greater anxiety at one month post MI". They also reported: "There were no significant differences between the two groups [for anxiety] at any other time points".One trial reporting relationship satisfaction and one trial reporting quality of life found no differences between intervention and control.No trial reported on satisfaction in how sexual issues were addressed in cardiac rehabilitation services.

AUTHORS' CONCLUSIONS

We found no high quality evidence to support the effectiveness of sexual counselling for sexual problems in patients with cardiovascular disease. There is a clear need for robust, methodologically rigorous, adequately powered RCTs to test the effectiveness of sexual counselling interventions for people with cardiovascular disease and their partners.