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.
Heart failure is a highly prevalent and common cardiovascular disorder. As with many other chronic diseases such as renal or liver failure, heart failure is associated with a high prevalence of erectile dysfunction (ED) in men. The exact numbers, however, are unknown, and data in women with heart failure are lacking. Risk factors that are common and contribute to the development of cardiovascular diseases such as coronary artery disease, which might lead to ischemic cardiomyopathy and heart failure, are also considered as risk factors for the development of male ED.1, 2 In particular, diabetes mellitus, hypertension, dyslipidemia and smoking are associated both with cardiovascular disorders and male impotence. In addition, use of medications such as thiazide diuretics, digoxin and, in part, β blockers are believed to worsen or sometimes even to cause sexual dysfunction in men.3 Male ED is defined as the persistent inability to achieve/maintain an erection sufficient for satisfactory sexual performance.1 In the Massachussetts Male Aging study, 52% of men between the ages of 40 and 70 years were suffering from some 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 risk factor for either the development or the coexistence of cardiovascular disorders. Despite the evidence, many health care providers do not pay much attention to potential sexual problems. Moreover, according to the second Princeton Consensus Conference guidelines, treatment of sexual dysfunction in men should be deferred if patients are considered at high risk,5 but these recommendations are not without controversy. The consequence is that many men with underlying heart disease and concomitant ED are not treated for ED. Therefore, it is important for physicians to address sexual concerns and potential treatment options in cardiac patients. The present study was designed to shed light in the often under-reported prevalence of female and male sexual dysfunction in a distinct population of patients with compensated chronic heart failure.
The protocol was approved by the institutional IRB. There was no outside funding for the study. Established questionnaires on sexual function and dysfunction were used to create a modified version of a gender-specific questionnaire directed towards patients with heart failure such as (1) the abridged International Index of Erectile Dysfunction (IIEF-5) questionnaire,6 (2) the Semi-structured interview on erectile dysfunction questionnaire7, (3) the quality of life questionnaire using the LiSat-8=Life Satisfaction questionnaire and the Index of Sexual Life questionnaire8 and (4) the Female Sexual Function Index for determination of female sexual dysfunction (desire, arousal, lubrication, orgasm, satisfaction, pain, total Female Sexual Function Index, number of sexual intercourse/month). Our modified version focused on three aspects: patient's sexual activity including any signs and symptoms of sexual dysfunction, the patients perception of potential causes and treatment desire and options, and the patient's evaluation of heath care with regard to provide adequate solutions in case of problems. The questions were grouped into the following clusters: (1) sexual desire/libido, (2) sexual function, (3) orgasm, (4) overall sexual satisfaction, (5) changes in sexual function over time, (6) perceptions and quality of life and (7) expectations for treatment and the role of health care providers.
Adult patients were included if they fulfilled the following criteria: established diagnosis of heart failure (>6 months), currently in New York Heart Association (NYHA) classes I–III, on medical management; ability to read and understand the study and the questions, willingness and informed consent to participate in the study. Only patients who stated that they were either married or were currently in a stable relationship with a partner and who stated that they are sexually active were enrolled. The frequency or kind of sexual activity was not part of the inclusion or exclusion criteria, nor was the sexual orientation. There were no other exclusion criteria. The study was approved by the institutional review board. The survey was conducted from October 2003 to November 2005 in a dedicated heart failure clinic setting. Only hemodynamically stable patients, who are not on inotropic support and not requiring hospital admission for acute decompensation, were enrolled. Patients were not randomized but prospectively approached by a physician not involved in the patients’ usual care. The questionnaire was blinded for analysis and no patient identifiers were available during analysis. All patients were given the option to either take the questionnaire to their homes and 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 knowledge. The completed questionnaire was then stored in separate envelopes in a secure location for further evaluation. All answers were analyzed. In some questions with more than one possible answer, some responses were grouped together for analysis.
A total of 105 patients were asked to participate in the study. Of those, five patients disagreed (one patient stated he did not want to participate, two patients stated that they were widows and had no sexual partner since many years that was missed at the initial inclusion visit, one male and one female patients both had partners who were chronically very sick and therefore thought that their information might not be valuable). One hundred patients who stated that they were sexually active participated in the questionnaire consisting of 76 males (age 58±18 years) and 24 females (age 59±16 years). The frequency of sexual activities, with or without a partner, was not part of inclusion criteria or the presented study design. The patients’ demographics are given in Table 1. For unknown reasons, in few cases not all questions were answered completely, that is there was either no reply or (in few questions) an answer option ‘not applicable’ was checked, so that the data given here do not necessarily always add up to 100% of responses.
In all, 76% of males and 87% of females reported reduced sexual desire or arousal, defined as any reduction in sexual desire in comparison to the patients’ former functionality without sexual problems to either a severe degree (very low desire), a moderate degree (low sexual desire) or any significant reduction (modest or higher reduction in desire). Therefore, 87% of women with heart failure were diagnosed with female sexual arousal disorder (Figure 1).
Sexual function/erectile function
Overall, 79% of men reported significantly reduced number of erections sufficient for penetration. Thirty-one percent of men stated that they never get an erection sufficient enough to penetrate; 84% of men reported problems in maintaining erections after penetration, therefore fulfilling the clinical diagnosis of ED (Figure 1). Only 8% of men reported not to have any problems in getting an erection sufficient for sexual intercourse or to maintain an 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 conditions prior to the onset of heart failure. Fifty percent of women reported a further decrease in lubrication during intercourse that in some even resulted in moderate to severe pain. A history of recurrent unsuccessful or interrupted intercourses because of the above reasons was reported in 76% of women.
Seventy-three percent of men reported difficulties with orgasm (which was defined as either no orgasm or premature orgasm). Sixty-two percent of women reported not being able to have an orgasm either in most (more than half of) attempts. Only 9% of women reported that they never had any difficulties to achieve an orgasm during sexual activity.
Overall, 80% of men and 83% of women stated not to be satisfied with their current sexual activities and their ability to have successful intercourse.
Changes over time
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, whereas 43% of men and 29% of women reported a steady decline in sexual function within the last 6 months. Most of the patients believed that a worsening heart condition and increasing age was the cause of their worsened sexual functionality. Overall, 68% of men and 50% of women recalled that sexual problems occurred prior to the onset of symptoms of heart failure or before a diagnosis of heart failure was established.
Perceptions and quality of life issues
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 38% of females stated that sex currently played an important role in their life. Overall, 62% of men and 45% of women claimed that their partners were understanding and supportive with regard to their sexual problems whereas 4% of men and 21% of women stated that their lifetime partner reacted non-supportive (‘being mad at me’) because of the 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 problems with their partner. Interestingly, more men than women (59 versus 31%) thought that sexual dysfunction was solely a consequence of the aging process and 40% of men and 25% of women believed that sexual activity could be in fact harmful to their present cardiac condition.
Role of health care providers and expectations for treatment
Overall, 68% of males and 50% of females believed that there are treatment options that could be applied for their individual case to improve sexual dysfunction. None of the women but 36% of men had tried some kind of (over-the-counter or over-the-internet) medication to self-medicate their sexual problems.
Most men (58%) had seen at least three physicians within the last 3 years for health related issues and most women (58%) had seen between 4 and 10 physicians within the last 3-year period. Sixty percent of men and 75% of the women recalled that none of the physicians consulted within the last 3 years had ever inquired about possible sexual problems (Figure 3). In contrast, most patients (61% of men and 38% of women, respectively) felt an urge to discuss these issues with their health care providers and were interested in receiving treatment to improve sexual dysfunction (Figure 4).
The main findings of our questionnaire are as follows: (1) Eighty-four percent of men with chronic but compensated heart failure in NYHA classes I–III fulfilled criteria for ED. (2) Eighty-seven percent of women with chronic compensated heart failure fulfilled criteria for female sexual arousal disorder, as derived from a self-assessment questionnaire. Furthermore, 52% of men and at least 38% of women admitted that sex is important and that sexual problems reduce their quality of life at the present time. (3) A large percentage of patients (68% males and 50% females) reported that their sexual 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 was really the case or if some degree of cardiac dysfunction was present before the onset of sexual dysfunction, since in many cases there was some controversy with regard to the patients’ history and the exact onset of symptoms versus the first diagnosis of either systolic dysfunction, a reduced ejection fraction or ‘heart failure’. (4) Interestingly, 68% of males and 50% of females believed in possible successful treatment options. Unfortunately, the majority of physicians who were involved in the medial care within the last 3 years did not actively interrogate about possible sexual problems in this patient cohort.
Sexual dysfunction in general
Erectile dysfunction is a commonly under-diagnosed disease entity that shares common risk factors and pathophysiologic mechanisms with cardiovascular disease,9 affecting approximately 30 million men in the United States.10, 11 One of the early studies to assess the prevalence of sexual dysfunction was published by Kinsey in 1948. He showed that 25% of men above the age of 65 years and 80% of men above 80 years suffered from some degree of sexual dysfunction.12 More recently, Feldman et al.4 reported the prevalence of impotence in a general population using data from the Massachusetts Male Aging Study. The authors showed that 52% of men exhibited sexual dysfunction, with 39% of men at 40 years of age and 67% among those 70 years or older.
Sexual dysfunction and heart failure
In contrast to data in the general population and the association between cardiovascular disease and ED, only little data exist in the heart failure population. Jaarsma et al.13 studied 73 patients with heart failure (mean age 70 years) and showed that in 80% of the men heart failure affected sexual function and relationships. Our questionnaire was conducted on a non-selected group of outpatients in stable condition (without any kind of ‘recovery’ after a recent event), which represent more a general population with an established diagnosis. Despite a relative good functional capacity in this cohort (all patients were in NYHA classes I–III), the prevalence of sexual dysfunction is much higher than it could be explained by reduced cardiac capacity alone. As reviewed in detail previously3 other factors than just a reduction in cardiac performance seem to play a role. Endothelial dysfunction,9 medication side effects14, 15 and psychologic aspects such as depression and isolation16 might all contribute to the development of sexual dysfunction in patients with chronic heart failure.
Female sexual dysfunction
Not surprisingly, there is even less data available on female sexual dysfunction. In 1999, Laumann et al.11 reported the prevalence of sexual dysfunction in women. Twenty-seven percent of women aged 50–59 reported lack of interest in sexual activity, and 23% of women were not able to achieve an orgasm. In addition, 27% of women reported insufficient lubrication, and a small number of participants (6%) reported anxiety regarding and in response to sexual performance. Sidi et al.17 reported sexual dysfunction in 30% of 230 Malaysian women (age 18–70 years), and, in addition, low sexual arousal, lack of lubrication, sexual dissatisfaction or sexual pain in more than 52%.
On the basis of the National Health and Social Life Survey of 1749 women, 43% have complaints of sexual dysfunction, but older women were not included in that particular trial.18 There is some evidence that disease processes and risk factors that are associated with male ED are also associated with female sexual dysfunction, indicating a possible common pathophysiologic mechanism.19
According to the American Foundation of Urologic Disease Consensus Panel, female sexual dysfunction is now often subdivided as lifelong versus acquired, generalized versus situational and organic versus psychogenic or mixed and encompasses several distinct disorders such as hypoactive sexual desire disorder, sexual aversion disorder, sexual arousal disorder, orgasmic disorder, sexual pain disorders such as dyspareunia, vaginismus or other sexual pain disorders.19
In our study, 84% of males and 87% of females with heart failure reported some degree of sexual dysfunction, close to data from Westlake who reported a significant decrease in sexual function and frequency of sexual relations in 75% of patients with advanced heart failure.20 These numbers are comparable to findings by Kloner et al.21, who estimated a 75% prevalence of ED in men with coronary artery disease. In a recently published paper by Hayes et al.22, 64% of (healthy) females experienced desire difficulty and up to 64% experienced arousal difficulties, compared to 78 and 87% of women with heart failure in our cohort. In a study assessing female sexual dysfunction in Turkey, it was shown that there were problems with desire in 48%, with arousal in 36% and with pain in 43% of the women.23
Due to our questionnaire data 79% of males had reduced number of erections sufficient for erection with 84% complaining of difficulties maintaining erection after penetration. This number is higher than previously reported data in men with coronary artery disease showing that 67% of men had difficulties maintaining erections sufficient for successful intercourse.20 A survey of 106 men above 16 years of age in the United Kingdom demonstrated that 32% had difficulties achieving erections and 20% had difficulties maintaining erections during intercourse,13 but, of note, these individuals were not heart failure patients.
Interestingly, 73% of our male patients and 62% of our female patients reported difficulties achieving an orgasm. In contrast, the National Health and Social Life Survey and other data showed that 15% of males and 23% of females between 50 and 59 years of age were unable to achieve orgasm.24 It was unclear, however, independent of ED, if and why orgastic capacity seems to be impaired in patients with heart failure,25 but reduced cardiac capacity as well as neurohormonal regulatory mechanism might contribute to these findings.
About 68% of men and 50% of women stated that their sexual problems occurred prior to the clinical onset of heart failure, confirming data previously published (67% of patients reported clinically apparent sexual dysfunction symptoms prior to onset of cardiovascular disease symptoms26).
Many patients were interested to discuss sexual problems with their physicians, men more than women (61 versus 38%), which is comparable to 40% of patients by Dunn et al.27 Reasons for the gender difference could be that men might be more affected by loss of sexual function than women28 and men might have more confidence in successful treatment secondary to the marketing efforts and clinical success data of PDE-5 inhibitors for treatment of ED while treatment for female sexual dysfunction is in its earliest stages. Surprisingly, our data reveal that most patients were never asked by their physicians within a 3-year period about possible sexual problems, which created general disappointment in health care with regard to concerns regarding sexual dysfunction among both men and women. However, since this is a single center study, we cannot rule out a selection bias due 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 dysfunction in both men and women with chronic compensated heart failure. The causes are multifactorial: (1) risk factors that might lead to coronary artery disease and heart disease also have been associated with ED in men, but also with sexual dysfunction in women; (2) endothelial dysfunction 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 the etiology; (3) medication side effects are potential causes for worsening sexual function; (4) reduced cardiac capacity and reduced conditioning secondary to reduced left ventricular function are considered additional contributing factors. Whether improvement of cardiac capacity, that is improved ejection fraction or cardiac output in response to therapy in fact does improve erectile function remains to be evaluated. (5) Heart failure frequently is associated with depression. Depression itself can either cause or worsen sexual dysfunction. Antidepressives such as selective serotonin receptor antagonists, in contrast, have major side effects with regard to a reduction of sexual desire and physiologic sexual function.
The time course of sexual dysfunction, however, is unknown. It seems that in most cases in women and in men, sexual dysfunction occurred first and, thus, could be considered as a risk or an early marker for sexual dysfunction, as it has been proposed before.29
The data presented here are from a blinded questionnaire from a non-selected outpatient cohort of patients with an established diagnosis of stable heart failure. We did not have a chance to evaluate specifics of the patients’ status (such as different age or NYHA groups) or the patients’ detailed history and therapy for correlation analysis since the analysis was blinded per study protocol. Moreover, we did not include a non-heart failure population as a control group; therefore, a selection bias within a particular group or region cannot be completely ruled out. Also, the patient's complaints about possible sexual dysfunction and the data given here were derived from a questionnaire that was designed to address this specific patient population and, thus, represents a modification of well-established standard questionnaires (such as the International Index of Erectile Dysfunction (IIEF-5)). The answers, however, were not clinically verified by further (urologic, gynecologic or psychiatric) investigations. Therefore, the study is purely descriptive but not analytic, and thus, might raise more questions than provide answers.
Heart failure appears to be closely associated with sexual dysfunction in both men and women. Special attention and awareness among health care providers is required to provide dedicated diagnostic approaches and treatment.
There was no funding for the study. The authors have no conflict of interest.
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).
About this article
International Journal of Impotence Research (2009)