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Obstetrics & Gynecology 2005;106:121-127
© 2005 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

Sexual Activity and Function in Postmenopausal Women With Heart Disease

Ilana B. Addis, MD MPH, Christine C. Ireland, MPH, Eric Vittinghoff, PhD, Feng Lin, MS, Cynthia A. Stuenkel, MD and Stephen Hulley, MD MPH

From the Department of Obstetrics and Gynecology, University of Arizona College of Medicine, Tucson, Arizona; Department of Epidemiology and Biostatistics, University of California, San Francisco; and University of California, San Diego, California.


   ABSTRACT
TOP
ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Objective: To examine the prevalence and correlates of sexual activity and function in postmenopausal women with heart disease.

Methods: We included baseline self-reported measures of sexual activity and the sexual problem scale from the Medical Outcomes Study in the Heart and Estrogen/Progestin Replacement Study (HERS), a study of 2,763 postmenopausal women, average age 67 years, with coronary disease and intact uteri. We used multivariable linear and logistic regression to identify independent correlates of sexual activity and dysfunction.

Results: Approximately 39% of the women in HERS were sexually active, and 65% of these reported at least 1 of 5 sexual problems (lack of interest, inability to relax, difficulty in arousal or in orgasm, and discomfort with sex). In multivariable analysis, factors independently associated with being sexually active included younger age, fewer years since menopause, being married, better self-reported health, higher parity, moderate alcohol use, not smoking, lack of chest discomfort, and not being depressed. Among the 1,091 women who were sexually active, lower sexual problem scores were associated with being unmarried, being better educated, having better self-reported health, and having higher body mass index.

Conclusion: Many women with heart disease continue to engage in sexual activity into their 70s, and two thirds of these report discomfort and other sexual function problems. Physicians should be aware that postmenopausal patients are sexually active and address the problems these women experience.

Level of Evidence: II-2

There is limited information on the prevalence, incidence, and antecedents of female sexual dysfunction. A new diagnostic classification system, the result of an international consensus development conference on female sexual dysfunction, refined categories found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and described 4 broad categories of female sexual dysfunction: sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders.1 Community-based studies indicate that the prevalence of female sexual dysfunction among all women is between 25% and 63%. An analysis of data from the National Health and Social Life Survey found that sexual dysfunction is more prevalent in women (43%) than in men (31%); prevalence varied among women of different racial groups and was associated with a history of traumatic sexual experiences and with deteriorating social position.5 Studies suggest that the same disease processes and risk factors that are associated with male erectile dysfunction, such as aging, hypertension, smoking, and pelvic surgery, are also associated with female sexual dysfunction.1 Sexual dysfunction may worsen mood, self-esteem, and quality of life, cause emotional distress, and lead to relationship problems.6

Menopausal status has been associated with diminished sexual activity.4 Two common problems are decrease in sexual desire and onset of dyspareunia.7 Reported prevalence of sexual dysfunction in postmenopausal women varies from 68% to 87% and is generally attributed to the decline in estrogen and testosterone levels.8 Other causes of sexual dysfunction in elderly women include chronic disease such as diabetes and coronary artery disease, psychosocial causes such as poor body image, and lack of a sexually competent partner. A substantial number of patients have sexual dysfunction after the diagnosis of cardiovascular disease.9 Ignorance about the risks of sexual activity after a heart attack and fear of death or another heart attack might contribute to sexual reticence. Underlying vascular disease and cardiac medications such as ß-blockers and other antihypertensive therapies may also contribute to sexual dysfunction.

To further investigate sexual function in older women with heart disease, we analyzed data from a cohort of postmenopausal women with coronary heart disease enrolled in the Heart and Estrogen/Progestin Study (HERS). Information was systematically collected on a wide range of self-reported symptoms at baseline and during the 4 years of treatment. Sexual dysfunction was measured using the sexual problem scale from the Medical Outcomes Study.10 We present here descriptive baseline data on the sexual activity and function of the women in HERS.


   MATERIALS AND METHODS
TOP
ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The methods for HERS have been described.11 Briefly, HERS was a randomized, double-blind, placebo-controlled trial designed to test the efficacy and safety of estrogen-plus-progestin therapy for prevention of recurrent coronary heart disease (CHD) events in women. The participants were postmenopausal women with a uterus and with CHD, as evidenced by prior myocardial infarction, coronary artery bypass graft surgery, percutaneous transluminal coronary angioplasty, or at least 50% occlusion of a major coronary artery. Patients were not eligible if they had had an myocardial infarction or a coronary revascularization procedure in the previous 6 months. Patients with a prior hysterectomy, contraindications to hormone therapy, or hormone therapy in the previous 3 months were excluded. Patients with other life-threatening illnesses were also excluded, as were those who were unable to return for follow-up visits. The HERS study was approved by the institutional review boards of the 20 clinical centers and the coordinating center at the University of California, San Francisco.

Between February 1993 and September 1994, 20 HERS centers recruited and randomized 2,763 women. A screening telephone call and 3 baseline clinic visits were performed to assess eligibility and collect baseline data. Baseline data were collected before randomization according to a standardized manual of operations. Each woman was randomly assigned to receive 1 tablet containing 0.625 mg conjugated estrogens plus 2.5 mg medroxyprogesterone acetate daily or an identical placebo. Participants were evaluated every 4 months. The trial was completed in July 1998.

The question ascertaining frequency of sexual activity had 6 possible responses, ranging from "not at all" to "more than once per week"; we categorized these responses as "frequent," "some," and "not at all." The sexual problem assessment scale was validated for populations with chronic disease in the Medical Outcomes Study.10 The instrument is designed to assess current sexual problems rather than changes in usual sexual functioning and includes 3 items appropriate for both women and men and 1 item appropriate for women only. The domains assessed include lack of sexual interest, inability to relax and enjoy sex, difficulty in becoming sexually aroused, and difficulty in having an orgasm, all during the last 4 weeks. Possible responses range from "not a problem" to "very much a problem." Summary scores are calculated by taking the average of the scores on the nonmissing items, scaled so that the range of the summary score is from 0 to 100.10 A higher summary score indicates more problems.

We analyzed discomfort during sex separately from the sexual problem scale. Women were asked how much of a problem discomfort during sexual intercourse had been in the past 4 weeks. Response options were the same as for the items combined in the sexual problems scale. Responses were dichotomized so that any complaint of discomfort during sex was coded as a problem.

Multivariable logistic models were used to assess the independent correlates of having any sexual activity, as well as the correlates of relatively frequent activity among women who were active; these outcomes were analyzed separately because different correlates were important to each. A multivariable linear model was used to identify factors associated with summary scores on the sexual problems scale. Finally, logistic regression was used to analyze any complaint of discomfort during sex. Backwards deletion, with a retention criterion of P < .2, was used to select models that minimize confounding. All analyses were done with SAS 8.2 (SAS Institute Inc, Cary, NC). P values < .05 were considered statistically significant.


   RESULTS
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
There were 2,763 women in the HERS trial. Baseline sexual activity and function data were available for all 2,763. The average age of the participants at baseline was 66.7 (± 6.7) years: 47% were 60–69 years old, 37% were 70–79 years old, and 15% were less than 60 years old. The majority of participants in HERS were white (89%), and approximately 80% had at least a high school education. A majority were also married (57%), with an average body mass index (BMI) of 28.6 (± 5.5), and most participants had been pregnant at least once (91%). Despite having coronary disease, only 24% rated themselves as being in poor or fair health, and only 36% reported chest pain in the past month. Forty-one percent had undergone coronary artery bypass grafting, and 43% had undergone percutaneous transluminal angioplasty. Fifty-one percent reported at least one myocardial infarction (Table 1).


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  		Table 1. Baseline Characteristics of Heart and Estrogen/Progestin Replacement Study Cohort

 

Overall, 1,091 women, or 39% of our cohort, reported sexual activity. In multivariable logistic analysis, sexual activity was associated with being married, higher parity, and moderate alcohol use (Table 2). Sexual activity was inversely associated with older age, increased years since menopause, vaginal dryness, current smoking, poor self-reported health, depression, and recent chest discomfort. The effect of marital status varied by clinical center, but a summary odds ratio estimate accounting for the interaction remained statistically significant (odds ratio 4.17, 95% confidence interval 1.55–11.2, P = .005).


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  		Table 2. Factors Associated With Reporting Any Sexual Activity at Baseline (n = 2,752)

 

Among the 1,091 women reporting any sexual activity, relatively frequent sexual activity (2–3 times a month or more) was associated with younger age, higher parity, and lack of recent chest discomfort (Table 3).


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  		Table 3. Factors Associated With More Frequent Sexual Activity Among Women Reporting Any Sexual Activity (n = 1,091)

 

Table 4 shows the prevalence of sexual problems among the 1,091 sexually active subjects. A total of 140 (13%) reported 1 problem, and 570 (52%) reported 2 or more such problems. The overall prevalences of reporting 1 or more problems were 65%, characterized as at least "a little bit" in magnitude; 44%, characterized as at least "somewhat of a problem"; and 20% characterized as "very much of a problem."


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  		Table 4. Sexual Problems Among Women Reporting Any Sexual Activity (n = 1,091)

 

In the multivariable linear model used to assess the sexual problems scale constructed from the first 4 items shown in Table 4, a lower summary score (indicating fewer or less bothersome sexual problems) was associated with more education and higher body mass index. Being married, being in poor or fair self-reported health, and suffering from depression were associated with higher summary scores (Table 5). We also found weak evidence for higher scores among women reporting urinary incontinence and lower scores among women farther from menopause (after taking age into account). The effects of age and depression varied significantly by clinical center; summary estimates for these factors accounting for the interaction were no longer statistically significant. Finally, discomfort during sex was associated with race/ethnicity, poor or fair self-reported health, incontinence, and depression; discomfort was also inversely associated with increased years since menopause, higher body mass index and parity, and current smoking (Table 6).


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  		Table 5. Factors Associated With Sexual Problems Summary Score Among Women Reporting Any Sexual Activity (n = 1,091)

 

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  		Table 6. Factors Associated With Discomfort During Sexual Intercourse Among Women Reporting Any Sexual Activity (n = 1,091)

 


   DISCUSSION
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
This large study of postmenopausal women with coronary artery disease showed that 39% of postmenopausal women with heart disease are sexually active and that 65% of these women reported at least one sexual problem. Among women who were sexually active, lower sexual problem summary scores were associated with being unmarried, better educated, better self-reported health, and higher body mass index.

Women in our youngest age group, 50–59 years old, more often reported "frequent" sex than women in the older age group. The decrease in sexual activity associated with aging is noted in most research about sexual practices in the elderly and may be explained by such things as diminished libido, higher chronic disease rates, and lack of or impairment of a partner.

We found that more people in good-to-excellent health reported "frequent" sex than those in fair-to-poor health. People in poor health tend to stop performing many activities of daily life, and one would expect sexual activity to fit into this category. Women who drank alcohol moderately (up to 2 drinks per day) were more likely to have sexual activity than those who drank no alcohol. Alcohol became nonsignificant when comparing women who drank more than 2 drinks a day with teetotalers. These results fit with research that has shown decreased inhibition with moderate alcohol use, but deleterious effects with heavier use, a group possibly identified in this study by the more-than-2-drinks-a-day group.12

Initial studies reported a decline in sexual activity in women as they age that is associated with a decline in subjective and objective health ratings.13,14 Diokno et al15 confirmed that sexual activity among both women and men decreases with age and is highly dependent on marital status. Additional population studies have confirmed these limited findings.16,17

Studies of general populations of women of all ages have found that 40–60% of women report some sexual dysfunction. Laumann et al5 published the widely quoted statistic that 43% of women have sexual dysfunction, encompassing lack of interest, inability to achieve orgasm, pain with sex, lack of pleasure, anxiety, and trouble lubricating. This analysis of the National Health and Social Life Survey also found that dysfunction in women was correlated with minority status, lower education level, and psychosocial stress. More recently, the same investigator reported prevalence of sexual dysfunction among 40- to 80-year-old women as 43% worldwide.22 Correlates for sexual dysfunction noted in previous studies include increasing age, low education level, and chronic disease.21

An analysis of sexual functioning in a slightly younger group of postmenopausal women (mean age 56 years) found that the most reported reason for sexual inactivity was lack of a healthy partner. In this study, 64% of the women reported sexual activity. A higher BMI, increased physical activity, increased life satisfaction, and unmarried status were related to higher global sexual function.23 In a cohort of older postmenopausal women (mean age 68 years) with osteoporosis, baseline data showed that 46% reported some sexual activity, and among those women the most reported problem was difficulty with orgasm.24

Cardiologists often do not adequately discuss sexual function with their heart patients, particularly their female patients.25 Given the paucity of sexual information for many heart patients, it seems possible that some women with a history of heart disease might be fearful about engaging in sexual activity, might be ignorant about risks (or lack of risks) of sexual activity, and might have partners who may also be fearful and reluctant participants, even if otherwise willing and able to engage in sexual relations. The cardiovascular response to sexual activity is not well understood.26 Several years ago, in an effort to help providers reassure heart patients about the safety of sexual activity, The Princeton Consensus Panel formulated recommendations for stratifying the cardiovascular risk of sexual activity in persons with a history of cardiovascular disease and advising patients about management of sexual dysfunction.27

We noted some surprising results when looking at the correlates of sexual problems. Among those who were sexually active, married women reported more sexual problems than unmarried women. This association remained significant in a model that stratified the subjects by frequency of sexual activity.

It has been reported in the literature that antihypertensive agents, specifically ß-blockers and thiazide diuretics, have a detrimental effect on sexual function in men.27 Little is said about women. A medical record review with questionnaire regarding sexual function in hypertensive women concluded that the disease, rather than the medication, was causing the sexual dysfunction.28 We did not find hypertensive medication to be a predictor of sexual problems. Selective serotonin reuptake inhibitors (SSRIs) are often associated with impairments of the sexual response cycle. Further research has found that SSRI use is usually associated with orgasmic difficulty in women.29,30 Our cohort had a very low rate of SSRI use, so it is difficult to make any conclusions about its lack of significance in our analysis.

Several limitations should be considered when interpreting our study results. Our cohort had an average age of 67 years, diagnosed heart disease, and was 87% white. Therefore, our findings are most applicable to the roughly 12% of postmenopausal women who meet these HERS entry criteria and may not apply to the general population of postmenopausal women. A second concern is whether women are reliable responders to self-report questions about their own sexual activity and function. At least the responses are relatively complete; of the 2,763 subjects, only 11 refused to answer the sexual activity and function questions.

In summary, we found that, in a cohort of postmenopausal women with heart disease, many women with heart disease continue to engage in sexual activity well into their 70s. Two thirds of those reporting sexual activity reported sexual problems, a rate that is similar to that reported by younger populations. Significant correlates for sexual dysfunction included BMI greater than 30, poor health, depression, and being married. Our results make clear that physicians need to be aware of this important aspect of women’s lives and should attempt to address any bothersome problems they might have. Future research is needed to develop holistic therapies that will address the complicated needs of older postmenopausal women with heart disease.


   Footnotes
 
Financial support for HERS was provided by Wyeth Ayerst Research, Madison, New Jersey.

Presented at the 52nd Annual Clinical Meeting of The American College of Obstetricians and Gynecologists, Philadelphia, Pennsylvania, May 1–5, 2004.

Address reprint requests to: Ilana B. Addis, MD, MPH, University of Arizona Health Sciences Center, 1501 North Campbell Avenue, P.O. Box 245078, Tucson, AZ 85724-5078; e-mail: iaddis{at}email.arizona.edu.

Financial Disclosure

The Heart and Estrogen/Progestin Replacement Study (HERS) was funded by a contract from Wyeth Ayerst Research. The HERS investigators received research support from the contract, including salaries, during the trial. The HERS investigators on this manuscript include Ms. Ireland, Ms. Feng, and Drs. Vittinghoff, Stuenkel, and Hulley. The HERS investigators were prohibited from owning any stock in the company, and none of the authors of this paper were paid for talks or consulting by the company during the HERS trial. The University of California, San Francisco, was the coordinating center for the trial and was responsible for data analysis and publications. This manuscript and all manuscripts from the HERS trial are written solely by the authors appearing on the manuscript.

doi:10.1097/01.AOG.0000165276.85777.fb


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 DISCUSSION
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I. B. Addis, S. K. Van Den Eeden, C. L. Wassel-Fyr, E. Vittinghoff, J. S. Brown, D. H. Thom, and for the Reproductive Risk Factors for Incontinence
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