Arch Gynecol Obstet DOI 10.1007/s00404-014-3537-5
GENERAL GYNECOLOGY
Effect of myocardial infarction on female sexual function in women Umran Oskay • Gulbeyaz Can • Gulsah Camcı
Received: 19 June 2014 / Accepted: 31 October 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The aim of this study was to assess sexual function in female patients with myocardial infarction (MI). Methods As research instruments, an interview form of 20 questions that questioned personal characteristics was developed by researchers, Female Sexual Function Index (FSFI) that evaluated sexual dysfunction was used. The Beck Depression Inventory was used to evaluate depression. Results In the course of this study, 45 female patients (62.73 ± 8.55 years) with MI and 50 control women were interviewed. The total FSFI score was 16.41 ± 8.04 in the MI group versus 23.13 ± 3.95 (P \ 0.001) in the control group. The prevalence of sexual dysfunction is significantly higher and the mean FSFI score was significantly lower in MI group women in comparison with the control group. Subscale scores of desire, arousal, lubrication and orgasm domains were lower than the other subscale scores in the MI group. Besides, 75.6 % of the women in the MI
U. Oskay (&) Department of Gynecologic and Obstetrics Nursing, Florence Nightingale Nursing Faculty of Istanbul University, Abide-i Hurriyet Street, Sisli/Mecidiyekoy, 34381 Istanbul, Turkey e-mail: [email protected] G. Can Department of Medical Nursing, Florence Nightingale Nursing Faculty of Istanbul University, Abide-i Hurriyet Street, Sisli/ Mecidiyekoy, 34381 Istanbul, Turkey e-mail: [email protected] G. Camcı Coronary Intensive Care Unit, Kocaeli University, Izmit, Kocaeli, Turkey e-mail: [email protected]
group and 48.2 % of women in the control group had a female sexual dysfunction. The frequency of intercourse was significantly lower in women with MI (1.55 ± 0.50 times last month) compared to the control group (2.14 ± 1.04 times last month). No significant differences were detected between the mean total BDI scores. But the correlation between FSFI and BDI total scores indicates that the increasing BDI scores in MI and control groups affected the total FSFI scores negatively. Conclusion Sexual problems are frequent in women with MI. Sexuality should be evaluated after MI and patients’ education and counseling may contribute to a better sexual function. Keywords infarction
Female Sexual function Myocardial
Introduction Sexual activity is an important issue for quality of life. Remaining sexually active is a central element in a longterm marriage, and patients rate the resumption of sexual activity after MI as extremely important [1, 2]. Nevertheless, studies report a significant reduction in sexual activity and sexual satisfaction after MI [3, 4]. Female sexual dysfunction has a major impact on quality of life and interpersonal relationships [5]. A decrease in sexual activity after a myocardial infarction for both women and men has been reported in several studies [3–7]. In addition, the quantity and quality of the sexual activity of women after MI have been found to be less than those of men [3]. The causes of sexual dysfunction are related to chronic health problems, anxiety, and depression and medication side effects. These often occur in combination [8]. A study
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by Drory et al. [3] showed that women report significantly less sexual activity and less satisfaction with sexual activity after myocardial infarction than before myocardial infarction. Despite the high prevalence of female sexual dysfunction (FSD), there are very few studies related to sexual function assessment in women with MI [3, 6, 8]. In addition, women with sexual dysfunction usually have not been sought for help from health professionals and are more likely to conceal their sexual problems because of cultural reasons in Turkey. This study aimed to evaluate the impact of MI on female sexual functioning.
Materials and methods This study was conducted at the Kocaeli University, Kocaeli Medical Faculty in Turkey, from September 2011 to April 2012, and included female patients admitted to the coronary intensive care unit for management of myocardial infarction. This study followed patient outcomes for 3 months after MI. The sample size was statistically computed according to annual number of patients, inclusion criteria, and literature on the prevalence of sexual issues in female patients with myocardial infarction. Data were collected from female patients with myocardial infarction who were admitted to the coronary intensive care unit of Kocaeli University, Kocaeli Medical Faculty for management of myocardial infarction. Study approval was obtained from the local ethics committee. All participants were married and were informed about the aim of the study, and written consent forms were obtained. Exclusion criteria included patients with a history of previous myocardial infarction, presence of advanced disease such as cancer, renal and heart failure, with a history of vaginal surgery and hysterectomy, with depression score (17 points and higher), such as antidepressant drug users and receiving hormonal replacement. Women with MI group comprised 45 women who had a regular sexual life. Control group comprised 50 volunteers who had a regular sexual life and who had no cardiac symptoms and had no depression (with depression score 17 points and higher), no drug users and receiving hormonal replacement. The volunteers were selected from the relatives and/or friends of patients who consulted to the cardiology polyclinic. Beck Depression Inventory As a reliable and validated method, the Beck Depression Inventory created by Beck in 1961 was adapted by Hisli [9] into Turkish version. The Beck Depression Inventory is a 21-item questionnaire survey. The current version of the
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questionnaire is designed for individuals of 13 years and older and comprises items relating to the symptoms of depression (e.g., hopelessness, irritability), cognitions (e.g., guilt or feelings of being punished), and physical symptoms (e.g., fatigue, weight loss, lack of interest in sex). If the inventory’s score is C17, it has been assumed that there is depression, and these patients and control group have been excluded from the study. The Female Sexual Function Index (FSFI) The Turkish version of the Female Sexual Function Index (FSFI) was used to evaluate the sexual function in women. The Cronbach’s alpha value of the scale was reported as 0.95 in Oksuz and Malhan’s reliability and validity study of the Female Sexual Function Index in the Turkish population. The Female Sexual Function Index (FSFI) is a known instrument that assesses sexual function in women with six domains: desire, arousal, lubrication, orgasm, satisfaction and pain during sexual intercourse. In women, the minimum and maximum scores are, respectively, 2 and 36. A cutoff FSFI score of 23 or less was accepted as ‘‘female sexual dysfunction’’ for the prevalence estimates in our study [10, 11]. In addition to FSFI, we asked women if they had worried about sexual life and partner relationships after myocardial infarction. Twelve weeks post discharge, all patients were invited to the Cardiology Clinic in hospital for health control and the assessment of sexual activity. The Female Sexual Function Index (FSFI) and Beck Depression Inventory (BDI) were filled out by the women themselves with guidance from the researcher. Data were analyzed in SPSS 11.5 for Windows (Statistical Program for Social Sciences) (Istanbul University). All data were summarized as mean ± standard deviation. Mann–Whitney U test was used to determine the relationship between FSFI scores. Pearson’s Chi square test was performed to investigate the relationships between grouping variables. Significance of P \ 0.05 was accepted.
Results The cross-sectional study sample consisted of 95 (45 study group, 50 control group) participants. An examination of the medical histories of the women with MI shows that many of them presented with acute anterior MI (35.5 %), 22.2 % presented with inferior MI, 8.9 % with inferior posterior MI, 6.7 % with ST segment elevation MI (STEMI) and 26.7 % with non-ST segment MI (NSTEMI). Only 35.6 % had percutaneous transluminal coronary angioplasty (PTCA) alone, whereas 64.4 % had both
Arch Gynecol Obstet Table 1 The characteristics of MI group and control group
Variables
MI group (n = 45) Mean ± SD
Control group (n = 50) Mean ± SD
Testa,
Age (years)
b
P value
62.73 ± 8.55
63.68 ± 8.07
ZMWU = -0.57
0.56
Educational level (years)
3.51 ± 2.34
3.40 ± 2.09
ZMWU = -0.11
0.90
Births
4.60 ± 2.51
4.22 ± 1.58
ZMWU = -0.14
0.88
Abortion/stillbirths
1.15 ± 1.55
0.84 ± 0.88
ZMWU = -0.35
0.72
29.12 ± 5.09
28.49 ± 3.93
ZMWU = -0.08
0.93
65 ± 6.69
64.44 ± 5.63
ZMWU = -0.48
0.62
38.22 ± 9.61 1.55 ± 0.50
36.44 ± 5.28 2.14 ± 1.04
ZMWU = -1.36 ZMWU = -2.74
0.17 0.006 P value
Body mass index Partner age Marriage years Sexual intercourse in the past month MI group n (%)
Control group n (%)
Testa,
Yes
37 (82.2)
42 (84)
v2 = 0.05
0.81
No
8 (17.8)
8 (16)
6 (13.3)
10 (20)
v2 = 0.75
0.42
39 (86.7)
40 (80)
Yes
20 (44.4)
15 (30)
v2 = 2.12
0.14
No
25 (55.6)
35 (70) v2 = 0.70
0.79
Variables
b
Menopause status
Smoking User Non-user Chronic illness
Sexual problem in male partner a
MWU Mann–Whitney U test
Yes
10 (22.2)
10 (20)
b
Chi square test
No
35 (77.8)
40 (80)
PTCA and stent procedures. Of the women receiving medication due to MI, 80 % were taking ACE inhibitors, 80 % angiotensin II receptor blockers (ARBs), and 84.4 % beta blocker drugs. The mean ages of the MI and control group were 62.73 ± 8.5 and 63.68 ± 8.07 years (range 42–80 years), respectively. The gynecological and obstetrical characteristics of the MI and control group were similar (P [ 0.05). Table 1 shows the demographic and other characteristics of the participants. There was no significant difference between mean ages, partner ages, married years, body mass index, menopause status, smoking, chronic illness and sexual problem in male partner. Among all participants, 92.6 % were postmenopausal. The frequency of intercourse was significantly lower in women with MI (1.55 ± 0.50 times last month) compared to the control group (2.14 ± 1.04 times last month). Table 2 shows the FSFI scores for each group on the basis of FSFI domains. The mean FSFI total score was significantly lower in women with MI compared with the control group (P \ 0.001). Women with MI reported lower desire, orgasm and lubrication scores in comparison with control group. Although the satisfaction and pain score were lower in patients with MI, this difference was not found to be statistically significant (Table 2). The prevalence of sexual dysfunction was higher in women with MI (75.6 %), compared with
Table 2 FSFI questionnaire scores of women with MI and control women Subscale
ZaMWU
P
0.88
-6.280
0.000
0.90
-2.701
0.007
4.27
1.14
-3.605
0.000
4.05
1.00
-5.982
0.000
MI group n = 45
Control group n = 50
Mean
±SD
Mean
±SD
Desire
1.82
0.79
3.24
Arousal
2.17
1.52
3.06
Lubrication
2.85
1.80
Orgasm
2.12
1.55
Satisfaction
4.03
1.13
4.11
1.07
-0.321
0.79
Pain
3.40
1.25
4.38
1.17
-1.596
0.11
16.41
8.04
23.13
3.95
-4.200
0.000
Total FSFI a
MWU Mann–Whitney U test
control group (48 %) according to the FSFI score cutoff value of 23 (v2 = 7,563, P \ 0.01). In addition to FSFI, we asked women if they had worried about sexual life and partner relationships after myocardial infarction. Forty patients (88.4 %) who resumed sex were worried that they may have another heart attack or die suddenly during intercourse, while 26 patients (57.8 %) mentioned that their husbands expressed their anxiety and fear from another heart attack or sudden death. None of the women reported receiving counseling about resuming sexual activity after an MI.
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The mean total BDI scores of the MI and control group were 12.55 ± 3.20 and 11.48 ± 2.90 (range 7–16), respectively. There was no significant difference between the mean total BDI scores (z = -1.44, P = 0.14). The relationship between FSFI and BDI Total Scores was assessed by Spearman’s rho correlation test in MI and control groups. The correlation between FSFI and BDI Total Scores showed that, total FSFI score was negatively affected by the increasing BDI scores in MI (r = -0.88, P = 0.000) and control groups (r = -0.84, P = 0.000).
Discussion Previous studies have reported that MI caused sexual problems such as loss of sexual desire, decrease in frequency of sexual intercourse, pain during sexual intercourse and orgasmic difficulties in women [2, 3, 6, 7]. The data in our study revealed that sexual dysfunction is more common in women with MI (75.6 %) than in the control group (48 %). It has been shown using the FSFI that the scores of sexual function of patients with MI were much lower than those of the control group. In this survey, the mean FSFI score was 16.41 ± 8.04 female patients with myocardial infarction and 23.13 ± 3.95 for the control group. Several studies, researching the sexual function in women with MI, have reported that about 60–80 % of control women were found to have female sexual dysfunction [1–7]. In this study among all participants, 92.6 % were postmenopausal and the mean ages of the MI and control group were 62.73 ± 8.5 and 63.68 ± 8.07 years (range 42–80 years). The prevalence of sexual dysfunction in postmenopausal women varies from 46.5 to 86.5 %, depending on the setting in which the study was performed [6, 12–14]. Various studies indicate a decrease in sexual desire and sexual activity with the increase in women’s age, especially for those aged 60 and over. Beutel et al. identified the proportion of low or lack of sexual desire in women in the 60–70 age group as 46 %. The proportion of continuing sexual activity was found 63 % in the same study [15]. DeLamater et al. [16] found the proportion of vaginal intercourse as 51.2 % in women aged between 50 and 59, and as 42.2 % in women aged between 60 and 69. In our study, 48 % of control subjects had FSD. The findings in this survey are parallel to these results in the literature. Continued sexual activity can be affected by factors such as good physical and mental health, a positive attitude toward sex in later life and a healthy partner, good sexual self-esteem, enjoyable past experience, and an attitude that values the importance of sex in couple relationships; hence, decline in sexual function is not always caused by the agerelated physical changes. Although age and decline in
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sexual interest are correlated with each other, negative effects of age on sexual desire seem to be related with health problems [12–17]. Cultural factors also have effects on both men’s and women’s sexual activity. Frequency of sexual activity is positively affected by marital satisfaction; and both marital satisfaction and frequency of sexual activity are associated with sexual intercourse and related factors such as frequency of orgasm per sexual encounter and sexual uninhibitedness [15–17]. Another factor which affects sexual activity in older women is the presence or absence of a partner. Given the exceeding life expectancy of women, older women will eventually become alone and thus have limited opportunities for intimate relationships. Studies indicate that men and women remain sexually active into their 80 s. When compared to women, men are reported to have greater incidence and frequency of sexual activity, which includes sexual intercourse as well. Presence of a partner in advanced ages was a major determinant of sexual activity. Low sexual activity can be predicted by women’s age and absence of a partner [16–18]. An evaluation of sexual issues in older women population should include considering the physiological and psychological changes women encounter in the aging process. Among female patients suffering from MI, sexual dysfunction has been little studied but found to be highly prevalent in the research. Drory et al. [3] compared sexual activity in men and women after an MI. Although both sexes experienced a decline in sexual activity and sexual satisfaction from before to after an MI, women particularly reported less sexual satisfaction than men. Those women who were older tended to have decreased sexual satisfaction and sexual frequency [19]. Yildiz and Pinar [20] compared sexual activity in men and women after an MI. They found that sexual dysfunction developed in 80 % of women with MI. In this study, the prevalence of sexual dysfunction was 75 %, which was high. Our results were similar with most of the other studies and indicate the increased incidence of sexual dysfunction in women with MI. Kaya et al. [6] reported that MI had a negative effect on sexual desire, sexual arousal, orgasmic capacity and lubrication. Several studies revealed that the women with MI had a significantly decreased level of sexual desire. These rates are between 60 and 83.3 % [6, 7, 21]. The mean total FSFI score and subscale scores of all domains, except the satisfaction and pain domain, were found lower in the MI group than those of control group (P \ 0.05). In this survey, subscale scores of desire domains were lower than other subscale scores in the MI group; and the frequency of intercourse per month was found to be significantly lower among patients with MI compared to the control group (1.55 versus 2.14, respectively; P \ 0.05).
Arch Gynecol Obstet
Loss of sexual desire in women suffering from myocardial infarction also may have reduced the frequency of sexual activity. These data indicate that sexual function scores of women with MI are poorer compared with the controls. The literature reports that 50–60 % of patients describe a decrease in sexual activity after an MI with the decrease more obvious among women compared with men, as well as among older patients compared with younger patients [22–24]. The main reason given for decreased sexual activity is a fear of triggering another MI, which creates stress and anxiety and thereby impairs marital life [1, 4–6, 24, 25]. In this study, we asked women if they had worried about sexual life and partner relationships after myocardial infarction. Forty patients (88.4 %) who resumed sex were worried that they may have another heart attack or die suddenly during intercourse, while 26 patients (57.8 %) mentioned that their husbands expressed their anxiety and fear from another heart attack or sudden death. The findings in this survey are parallel to these results in the literature. Depression is known to be one of the most significant psychogenic factors in women; which leads to a loss of interest and a decrease in the ability to engage in a sexual relationship. Medicine which is used in the treatment of these disorders can cause sexual side effects. Anti-psychotic medications, SSRI antidepressants, monoamine oxidase (MAO) inhibiters, and sedative drugs can cause a decrease in sexual desire [26–28]. Therefore, the women in the MI and control groups who had high depression levels or used antidepressants were not included in the study. In this study, there was no significant difference between the mean total BDI scores of the MI and control group (z = 1.44 P = 0.14). But the correlation between FSFI and BDI Total Scores showed that total FSFI score was negatively affected by the increasing BDI scores in MI and control groups. Fabre and Smith [29] found that a higher the depression score correlated with a lower the level of sexual functioning. Laumann et al. [30] concluded that reduced sexual functioning in later life can primarily be caused by stress, a major contributor to anxiety and depression. The findings in this survey are parallel to these results in the literature. Psychological impacts of chronic illnesses also have effects on sexual functioning. Sexual function and response may be negatively affected by chronic disorders such as cardiovascular disease, hypertension, diabetes and arthritis [26, 27]. Psychological impacts of chronic illnesses also have effects on sexual functioning. A number of studies found this proportion higher in women who had MI. In Parashar et al. [31] prospective study of post-MI patients, depressive symptoms modestly accounted for women’s worse outcome after MI.
Depression and anxiety risk factors for MI and impairment of sexuality. A risk indicator for arteriosclerosis and for heart disease or even a consequence of heart disease could be sexual dysfunction. With a prevalence of depression levels almost twice those of men, women— especially younger women—are inclined to depression in the peri- and post-MI period. The reasons are that depression is an independent risk factor for acute coronary syndrome and that there is a great overlap between symptoms of depression and coronary ischemia [30–34]. Brody [32] reviewed the related literature and reported that higher quality of intimate relationships, lower rates of depressive and anxiety symptoms, and improved cardiovascular health in both men and women are correlated with engaging in penile–vaginal intercourse. It is important to consider the physiologic and psychological changes that occur in female patients with MI when evaluating sexual issues in that population. In previous literature, mental health, depression and anxiety have been considered important in the decline of sexual activity among women. Of these factors, we could analyze only depression level. This was a limitation of the study. In the study, none of the women reported receiving counseling about resuming sexual activity after an MI. There is a lack of knowledge regarding the sexual life and coexistence of women who have had a myocardial infarction and many patients believe that MI has a negative impact. In several studies, revealed that inadequate and differing information about sexual intercourse from health care professionals generated anxiety and fear in patients with MI [35–37]. Women who have had an MI reported a lack of information and counseling on sexual issues from health care professionals. Absence of counseling at hospital discharge about when to resume sexual activity was a significant predictor of loss of activity for women with MI [38]. In parallel to our findings, some other studies report that MI patients are not given efficient knowledge and counseling regarding their sexual function and sexual life.
Conclusion Sexual dysfunction is a common problem in patients with MI that should be considered by clinicians. Thus, efforts to address sexual dysfunctions in women with MI should begin with a comprehensive assessment. Development of an effective intervention might include brief assessment of patient self-efficacy and coping style early in the course of MI care and use this information to personalize care for improvement of sexual and other outcomes.
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MI is an important factor contributing to female sexual dysfunction, but research into sexual dysfunction in women with MI is very limited. This study contributes to the limited previous studies that evaluated sexual function in women with MI in Turkey. Further research is needed to fully understand the mechanisms for sexual dysfunction and viable treatment options. Results of this study cannot be generalized because of the small number of participants in the sample group. The study has a few limitations; it comprised of only women admitted to one center. Larger and multicenter studies that will include women with MI are needed to obtain strong results. Acknowledgments of the study. Conflict of interest interest.
The authors would like to thank the participants
None of the authors have any conflicts of
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14. Birkha¨user MH (2009) Quality of life and sexuality issues in aging women. Climacteric 12:52–57 15. Beutel ME, Sto¨bel-Richter Y, Bra¨hler E (2008) Sexual desire and sexual activity of men and women across their lifespans: results from a representative German community survey. BJU Int 101:76–82 16. DeLamater J, Hyde JS, Fong MC (2008) Sexual satisfaction in the seventh decade of life. J Sex Marital Ther 34:439–454 17. DeLamater J (2012) Sexual expression in later life: a review and synthesis. J Sex Res 49:125–141 18. Karraker A, Delamater J, Schwartz CR (2011) Sexual frequency decline from midlife to later life. J Gerontol B Psychol Sci Soc Sci 66:502–512 19. McCall-Hosenfeld JS, Jaramillo SA, Legault C et al (2008) Members of Women’s Health Initiative-Observational Study. Correlates of sexual satisfaction among sexually active postmenopausal women in the Women’s Health Initiative-Observational Study. J Gen Intern Med 23:2000–2009 20. Yildiz H, Pinar R (2004) Sexual dysfunction in patients with myocardial infarction. Anadolu Kardiyol Derg 4:309–317 21. Eyada M, Atwa M (2007) Sexual function in female patients with unstable angina or non-ST-elevation myocardial infarction. J Sex Med 4:1373–1380 22. Addis IB, Ireland CC, Vittinghoff E, Lin F, Stuenkel CA, Hulley S (2005) Sexual activity and function in postmenopausal women with heart disease. Obstet Gynecol 106:121–127 23. Gu¨nzler C, Kriston L, Agyemang A, Riemann D, Berner MM (2010) Sexual dysfunction and its consequences in patients with cardiovascular diseases. Herz 35:410–419 24. Søderberg LH, Johansen PP, Herning M, Berg SK (2013) Women’s experiences of sexual health after first-time myocardial infarction. J Clin Nurs 22:3532–3540 25. Kartal O, Tatli E, Inal V, Yamanel L (2006) Sexual activity in cardiac patients. Anadolu Kardiyol Derg 6:264–269 26. DeLamater JD, Sill M (2005) Sexual desire in later life. J Sex Res 42:138–149 27. Moreira ED, Glasser DB, King R, Duarte F, Gingell C (2008) The Global Study of Sexual Attitudes, and Behaviors Investigators Group; Sexual difficulties and help-seeking among mature adults in Australia: results from the global study of sexual attitudes and behaviours. Sexual Health 5:227–234 28. Wood A, Runciman R, Wylie KR, McManus R (2012) An update on female sexual function and dysfunction in old age and its relevance to old age psychiatry. Aging Dis 3:373–384 29. Fabre LF, Smith LC (2012) The effect of major depression on sexual function in women. J Sex Med 9:231–239 30. Laumann EO, Das A, Waite LJ (2008) Sexual dysfunction among older adults: prevalence and risk factors from a nationally representative US probability sample of men and women 57–85 years of age. J Sex Med 5:2300–2311 31. Parashar S, Rumsfeld JS, Reid KJ, Buchanan D, Dawood N, Khizer S, Lichtman J, Vaccarino V (2009) Impact of depression on sex differences in outcome after myocardial infarction. Circ Cardiovasc Qual Outcomes 2:33–40 32. Brody S (2010) The relative health benefits of different sexual activities. J Sex Med 7:1336–1361 33. Roest AM, Martens EJ, de Jonge P, Denollet J (2010) Anxiety and risk of incident coronary heart disease: a meta-analysis. J Am Coll Cardiol 56:38–46 34. Tecce MA, Dasgupta I, Doherty JU (2003) Heart disease in older women: gender differences affect diagnosis and treatment. Geriatrics 58:33–39 35. Ivarsson B, Fridlund B, Sjo¨berg T (2009) Information from health care professionals about sexual function and coexistence after myocardial infarction: a Swedish national survey. Heart Lung 38:330–335
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GENERAL GYNECOLOGY
Effect of myocardial infarction on female sexual function in women Umran Oskay • Gulbeyaz Can • Gulsah Camcı
Received: 19 June 2014 / Accepted: 31 October 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The aim of this study was to assess sexual function in female patients with myocardial infarction (MI). Methods As research instruments, an interview form of 20 questions that questioned personal characteristics was developed by researchers, Female Sexual Function Index (FSFI) that evaluated sexual dysfunction was used. The Beck Depression Inventory was used to evaluate depression. Results In the course of this study, 45 female patients (62.73 ± 8.55 years) with MI and 50 control women were interviewed. The total FSFI score was 16.41 ± 8.04 in the MI group versus 23.13 ± 3.95 (P \ 0.001) in the control group. The prevalence of sexual dysfunction is significantly higher and the mean FSFI score was significantly lower in MI group women in comparison with the control group. Subscale scores of desire, arousal, lubrication and orgasm domains were lower than the other subscale scores in the MI group. Besides, 75.6 % of the women in the MI
U. Oskay (&) Department of Gynecologic and Obstetrics Nursing, Florence Nightingale Nursing Faculty of Istanbul University, Abide-i Hurriyet Street, Sisli/Mecidiyekoy, 34381 Istanbul, Turkey e-mail: [email protected] G. Can Department of Medical Nursing, Florence Nightingale Nursing Faculty of Istanbul University, Abide-i Hurriyet Street, Sisli/ Mecidiyekoy, 34381 Istanbul, Turkey e-mail: [email protected] G. Camcı Coronary Intensive Care Unit, Kocaeli University, Izmit, Kocaeli, Turkey e-mail: [email protected]
group and 48.2 % of women in the control group had a female sexual dysfunction. The frequency of intercourse was significantly lower in women with MI (1.55 ± 0.50 times last month) compared to the control group (2.14 ± 1.04 times last month). No significant differences were detected between the mean total BDI scores. But the correlation between FSFI and BDI total scores indicates that the increasing BDI scores in MI and control groups affected the total FSFI scores negatively. Conclusion Sexual problems are frequent in women with MI. Sexuality should be evaluated after MI and patients’ education and counseling may contribute to a better sexual function. Keywords infarction
Female Sexual function Myocardial
Introduction Sexual activity is an important issue for quality of life. Remaining sexually active is a central element in a longterm marriage, and patients rate the resumption of sexual activity after MI as extremely important [1, 2]. Nevertheless, studies report a significant reduction in sexual activity and sexual satisfaction after MI [3, 4]. Female sexual dysfunction has a major impact on quality of life and interpersonal relationships [5]. A decrease in sexual activity after a myocardial infarction for both women and men has been reported in several studies [3–7]. In addition, the quantity and quality of the sexual activity of women after MI have been found to be less than those of men [3]. The causes of sexual dysfunction are related to chronic health problems, anxiety, and depression and medication side effects. These often occur in combination [8]. A study
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by Drory et al. [3] showed that women report significantly less sexual activity and less satisfaction with sexual activity after myocardial infarction than before myocardial infarction. Despite the high prevalence of female sexual dysfunction (FSD), there are very few studies related to sexual function assessment in women with MI [3, 6, 8]. In addition, women with sexual dysfunction usually have not been sought for help from health professionals and are more likely to conceal their sexual problems because of cultural reasons in Turkey. This study aimed to evaluate the impact of MI on female sexual functioning.
Materials and methods This study was conducted at the Kocaeli University, Kocaeli Medical Faculty in Turkey, from September 2011 to April 2012, and included female patients admitted to the coronary intensive care unit for management of myocardial infarction. This study followed patient outcomes for 3 months after MI. The sample size was statistically computed according to annual number of patients, inclusion criteria, and literature on the prevalence of sexual issues in female patients with myocardial infarction. Data were collected from female patients with myocardial infarction who were admitted to the coronary intensive care unit of Kocaeli University, Kocaeli Medical Faculty for management of myocardial infarction. Study approval was obtained from the local ethics committee. All participants were married and were informed about the aim of the study, and written consent forms were obtained. Exclusion criteria included patients with a history of previous myocardial infarction, presence of advanced disease such as cancer, renal and heart failure, with a history of vaginal surgery and hysterectomy, with depression score (17 points and higher), such as antidepressant drug users and receiving hormonal replacement. Women with MI group comprised 45 women who had a regular sexual life. Control group comprised 50 volunteers who had a regular sexual life and who had no cardiac symptoms and had no depression (with depression score 17 points and higher), no drug users and receiving hormonal replacement. The volunteers were selected from the relatives and/or friends of patients who consulted to the cardiology polyclinic. Beck Depression Inventory As a reliable and validated method, the Beck Depression Inventory created by Beck in 1961 was adapted by Hisli [9] into Turkish version. The Beck Depression Inventory is a 21-item questionnaire survey. The current version of the
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questionnaire is designed for individuals of 13 years and older and comprises items relating to the symptoms of depression (e.g., hopelessness, irritability), cognitions (e.g., guilt or feelings of being punished), and physical symptoms (e.g., fatigue, weight loss, lack of interest in sex). If the inventory’s score is C17, it has been assumed that there is depression, and these patients and control group have been excluded from the study. The Female Sexual Function Index (FSFI) The Turkish version of the Female Sexual Function Index (FSFI) was used to evaluate the sexual function in women. The Cronbach’s alpha value of the scale was reported as 0.95 in Oksuz and Malhan’s reliability and validity study of the Female Sexual Function Index in the Turkish population. The Female Sexual Function Index (FSFI) is a known instrument that assesses sexual function in women with six domains: desire, arousal, lubrication, orgasm, satisfaction and pain during sexual intercourse. In women, the minimum and maximum scores are, respectively, 2 and 36. A cutoff FSFI score of 23 or less was accepted as ‘‘female sexual dysfunction’’ for the prevalence estimates in our study [10, 11]. In addition to FSFI, we asked women if they had worried about sexual life and partner relationships after myocardial infarction. Twelve weeks post discharge, all patients were invited to the Cardiology Clinic in hospital for health control and the assessment of sexual activity. The Female Sexual Function Index (FSFI) and Beck Depression Inventory (BDI) were filled out by the women themselves with guidance from the researcher. Data were analyzed in SPSS 11.5 for Windows (Statistical Program for Social Sciences) (Istanbul University). All data were summarized as mean ± standard deviation. Mann–Whitney U test was used to determine the relationship between FSFI scores. Pearson’s Chi square test was performed to investigate the relationships between grouping variables. Significance of P \ 0.05 was accepted.
Results The cross-sectional study sample consisted of 95 (45 study group, 50 control group) participants. An examination of the medical histories of the women with MI shows that many of them presented with acute anterior MI (35.5 %), 22.2 % presented with inferior MI, 8.9 % with inferior posterior MI, 6.7 % with ST segment elevation MI (STEMI) and 26.7 % with non-ST segment MI (NSTEMI). Only 35.6 % had percutaneous transluminal coronary angioplasty (PTCA) alone, whereas 64.4 % had both
Arch Gynecol Obstet Table 1 The characteristics of MI group and control group
Variables
MI group (n = 45) Mean ± SD
Control group (n = 50) Mean ± SD
Testa,
Age (years)
b
P value
62.73 ± 8.55
63.68 ± 8.07
ZMWU = -0.57
0.56
Educational level (years)
3.51 ± 2.34
3.40 ± 2.09
ZMWU = -0.11
0.90
Births
4.60 ± 2.51
4.22 ± 1.58
ZMWU = -0.14
0.88
Abortion/stillbirths
1.15 ± 1.55
0.84 ± 0.88
ZMWU = -0.35
0.72
29.12 ± 5.09
28.49 ± 3.93
ZMWU = -0.08
0.93
65 ± 6.69
64.44 ± 5.63
ZMWU = -0.48
0.62
38.22 ± 9.61 1.55 ± 0.50
36.44 ± 5.28 2.14 ± 1.04
ZMWU = -1.36 ZMWU = -2.74
0.17 0.006 P value
Body mass index Partner age Marriage years Sexual intercourse in the past month MI group n (%)
Control group n (%)
Testa,
Yes
37 (82.2)
42 (84)
v2 = 0.05
0.81
No
8 (17.8)
8 (16)
6 (13.3)
10 (20)
v2 = 0.75
0.42
39 (86.7)
40 (80)
Yes
20 (44.4)
15 (30)
v2 = 2.12
0.14
No
25 (55.6)
35 (70) v2 = 0.70
0.79
Variables
b
Menopause status
Smoking User Non-user Chronic illness
Sexual problem in male partner a
MWU Mann–Whitney U test
Yes
10 (22.2)
10 (20)
b
Chi square test
No
35 (77.8)
40 (80)
PTCA and stent procedures. Of the women receiving medication due to MI, 80 % were taking ACE inhibitors, 80 % angiotensin II receptor blockers (ARBs), and 84.4 % beta blocker drugs. The mean ages of the MI and control group were 62.73 ± 8.5 and 63.68 ± 8.07 years (range 42–80 years), respectively. The gynecological and obstetrical characteristics of the MI and control group were similar (P [ 0.05). Table 1 shows the demographic and other characteristics of the participants. There was no significant difference between mean ages, partner ages, married years, body mass index, menopause status, smoking, chronic illness and sexual problem in male partner. Among all participants, 92.6 % were postmenopausal. The frequency of intercourse was significantly lower in women with MI (1.55 ± 0.50 times last month) compared to the control group (2.14 ± 1.04 times last month). Table 2 shows the FSFI scores for each group on the basis of FSFI domains. The mean FSFI total score was significantly lower in women with MI compared with the control group (P \ 0.001). Women with MI reported lower desire, orgasm and lubrication scores in comparison with control group. Although the satisfaction and pain score were lower in patients with MI, this difference was not found to be statistically significant (Table 2). The prevalence of sexual dysfunction was higher in women with MI (75.6 %), compared with
Table 2 FSFI questionnaire scores of women with MI and control women Subscale
ZaMWU
P
0.88
-6.280
0.000
0.90
-2.701
0.007
4.27
1.14
-3.605
0.000
4.05
1.00
-5.982
0.000
MI group n = 45
Control group n = 50
Mean
±SD
Mean
±SD
Desire
1.82
0.79
3.24
Arousal
2.17
1.52
3.06
Lubrication
2.85
1.80
Orgasm
2.12
1.55
Satisfaction
4.03
1.13
4.11
1.07
-0.321
0.79
Pain
3.40
1.25
4.38
1.17
-1.596
0.11
16.41
8.04
23.13
3.95
-4.200
0.000
Total FSFI a
MWU Mann–Whitney U test
control group (48 %) according to the FSFI score cutoff value of 23 (v2 = 7,563, P \ 0.01). In addition to FSFI, we asked women if they had worried about sexual life and partner relationships after myocardial infarction. Forty patients (88.4 %) who resumed sex were worried that they may have another heart attack or die suddenly during intercourse, while 26 patients (57.8 %) mentioned that their husbands expressed their anxiety and fear from another heart attack or sudden death. None of the women reported receiving counseling about resuming sexual activity after an MI.
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The mean total BDI scores of the MI and control group were 12.55 ± 3.20 and 11.48 ± 2.90 (range 7–16), respectively. There was no significant difference between the mean total BDI scores (z = -1.44, P = 0.14). The relationship between FSFI and BDI Total Scores was assessed by Spearman’s rho correlation test in MI and control groups. The correlation between FSFI and BDI Total Scores showed that, total FSFI score was negatively affected by the increasing BDI scores in MI (r = -0.88, P = 0.000) and control groups (r = -0.84, P = 0.000).
Discussion Previous studies have reported that MI caused sexual problems such as loss of sexual desire, decrease in frequency of sexual intercourse, pain during sexual intercourse and orgasmic difficulties in women [2, 3, 6, 7]. The data in our study revealed that sexual dysfunction is more common in women with MI (75.6 %) than in the control group (48 %). It has been shown using the FSFI that the scores of sexual function of patients with MI were much lower than those of the control group. In this survey, the mean FSFI score was 16.41 ± 8.04 female patients with myocardial infarction and 23.13 ± 3.95 for the control group. Several studies, researching the sexual function in women with MI, have reported that about 60–80 % of control women were found to have female sexual dysfunction [1–7]. In this study among all participants, 92.6 % were postmenopausal and the mean ages of the MI and control group were 62.73 ± 8.5 and 63.68 ± 8.07 years (range 42–80 years). The prevalence of sexual dysfunction in postmenopausal women varies from 46.5 to 86.5 %, depending on the setting in which the study was performed [6, 12–14]. Various studies indicate a decrease in sexual desire and sexual activity with the increase in women’s age, especially for those aged 60 and over. Beutel et al. identified the proportion of low or lack of sexual desire in women in the 60–70 age group as 46 %. The proportion of continuing sexual activity was found 63 % in the same study [15]. DeLamater et al. [16] found the proportion of vaginal intercourse as 51.2 % in women aged between 50 and 59, and as 42.2 % in women aged between 60 and 69. In our study, 48 % of control subjects had FSD. The findings in this survey are parallel to these results in the literature. Continued sexual activity can be affected by factors such as good physical and mental health, a positive attitude toward sex in later life and a healthy partner, good sexual self-esteem, enjoyable past experience, and an attitude that values the importance of sex in couple relationships; hence, decline in sexual function is not always caused by the agerelated physical changes. Although age and decline in
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sexual interest are correlated with each other, negative effects of age on sexual desire seem to be related with health problems [12–17]. Cultural factors also have effects on both men’s and women’s sexual activity. Frequency of sexual activity is positively affected by marital satisfaction; and both marital satisfaction and frequency of sexual activity are associated with sexual intercourse and related factors such as frequency of orgasm per sexual encounter and sexual uninhibitedness [15–17]. Another factor which affects sexual activity in older women is the presence or absence of a partner. Given the exceeding life expectancy of women, older women will eventually become alone and thus have limited opportunities for intimate relationships. Studies indicate that men and women remain sexually active into their 80 s. When compared to women, men are reported to have greater incidence and frequency of sexual activity, which includes sexual intercourse as well. Presence of a partner in advanced ages was a major determinant of sexual activity. Low sexual activity can be predicted by women’s age and absence of a partner [16–18]. An evaluation of sexual issues in older women population should include considering the physiological and psychological changes women encounter in the aging process. Among female patients suffering from MI, sexual dysfunction has been little studied but found to be highly prevalent in the research. Drory et al. [3] compared sexual activity in men and women after an MI. Although both sexes experienced a decline in sexual activity and sexual satisfaction from before to after an MI, women particularly reported less sexual satisfaction than men. Those women who were older tended to have decreased sexual satisfaction and sexual frequency [19]. Yildiz and Pinar [20] compared sexual activity in men and women after an MI. They found that sexual dysfunction developed in 80 % of women with MI. In this study, the prevalence of sexual dysfunction was 75 %, which was high. Our results were similar with most of the other studies and indicate the increased incidence of sexual dysfunction in women with MI. Kaya et al. [6] reported that MI had a negative effect on sexual desire, sexual arousal, orgasmic capacity and lubrication. Several studies revealed that the women with MI had a significantly decreased level of sexual desire. These rates are between 60 and 83.3 % [6, 7, 21]. The mean total FSFI score and subscale scores of all domains, except the satisfaction and pain domain, were found lower in the MI group than those of control group (P \ 0.05). In this survey, subscale scores of desire domains were lower than other subscale scores in the MI group; and the frequency of intercourse per month was found to be significantly lower among patients with MI compared to the control group (1.55 versus 2.14, respectively; P \ 0.05).
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Loss of sexual desire in women suffering from myocardial infarction also may have reduced the frequency of sexual activity. These data indicate that sexual function scores of women with MI are poorer compared with the controls. The literature reports that 50–60 % of patients describe a decrease in sexual activity after an MI with the decrease more obvious among women compared with men, as well as among older patients compared with younger patients [22–24]. The main reason given for decreased sexual activity is a fear of triggering another MI, which creates stress and anxiety and thereby impairs marital life [1, 4–6, 24, 25]. In this study, we asked women if they had worried about sexual life and partner relationships after myocardial infarction. Forty patients (88.4 %) who resumed sex were worried that they may have another heart attack or die suddenly during intercourse, while 26 patients (57.8 %) mentioned that their husbands expressed their anxiety and fear from another heart attack or sudden death. The findings in this survey are parallel to these results in the literature. Depression is known to be one of the most significant psychogenic factors in women; which leads to a loss of interest and a decrease in the ability to engage in a sexual relationship. Medicine which is used in the treatment of these disorders can cause sexual side effects. Anti-psychotic medications, SSRI antidepressants, monoamine oxidase (MAO) inhibiters, and sedative drugs can cause a decrease in sexual desire [26–28]. Therefore, the women in the MI and control groups who had high depression levels or used antidepressants were not included in the study. In this study, there was no significant difference between the mean total BDI scores of the MI and control group (z = 1.44 P = 0.14). But the correlation between FSFI and BDI Total Scores showed that total FSFI score was negatively affected by the increasing BDI scores in MI and control groups. Fabre and Smith [29] found that a higher the depression score correlated with a lower the level of sexual functioning. Laumann et al. [30] concluded that reduced sexual functioning in later life can primarily be caused by stress, a major contributor to anxiety and depression. The findings in this survey are parallel to these results in the literature. Psychological impacts of chronic illnesses also have effects on sexual functioning. Sexual function and response may be negatively affected by chronic disorders such as cardiovascular disease, hypertension, diabetes and arthritis [26, 27]. Psychological impacts of chronic illnesses also have effects on sexual functioning. A number of studies found this proportion higher in women who had MI. In Parashar et al. [31] prospective study of post-MI patients, depressive symptoms modestly accounted for women’s worse outcome after MI.
Depression and anxiety risk factors for MI and impairment of sexuality. A risk indicator for arteriosclerosis and for heart disease or even a consequence of heart disease could be sexual dysfunction. With a prevalence of depression levels almost twice those of men, women— especially younger women—are inclined to depression in the peri- and post-MI period. The reasons are that depression is an independent risk factor for acute coronary syndrome and that there is a great overlap between symptoms of depression and coronary ischemia [30–34]. Brody [32] reviewed the related literature and reported that higher quality of intimate relationships, lower rates of depressive and anxiety symptoms, and improved cardiovascular health in both men and women are correlated with engaging in penile–vaginal intercourse. It is important to consider the physiologic and psychological changes that occur in female patients with MI when evaluating sexual issues in that population. In previous literature, mental health, depression and anxiety have been considered important in the decline of sexual activity among women. Of these factors, we could analyze only depression level. This was a limitation of the study. In the study, none of the women reported receiving counseling about resuming sexual activity after an MI. There is a lack of knowledge regarding the sexual life and coexistence of women who have had a myocardial infarction and many patients believe that MI has a negative impact. In several studies, revealed that inadequate and differing information about sexual intercourse from health care professionals generated anxiety and fear in patients with MI [35–37]. Women who have had an MI reported a lack of information and counseling on sexual issues from health care professionals. Absence of counseling at hospital discharge about when to resume sexual activity was a significant predictor of loss of activity for women with MI [38]. In parallel to our findings, some other studies report that MI patients are not given efficient knowledge and counseling regarding their sexual function and sexual life.
Conclusion Sexual dysfunction is a common problem in patients with MI that should be considered by clinicians. Thus, efforts to address sexual dysfunctions in women with MI should begin with a comprehensive assessment. Development of an effective intervention might include brief assessment of patient self-efficacy and coping style early in the course of MI care and use this information to personalize care for improvement of sexual and other outcomes.
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MI is an important factor contributing to female sexual dysfunction, but research into sexual dysfunction in women with MI is very limited. This study contributes to the limited previous studies that evaluated sexual function in women with MI in Turkey. Further research is needed to fully understand the mechanisms for sexual dysfunction and viable treatment options. Results of this study cannot be generalized because of the small number of participants in the sample group. The study has a few limitations; it comprised of only women admitted to one center. Larger and multicenter studies that will include women with MI are needed to obtain strong results. Acknowledgments of the study. Conflict of interest interest.
The authors would like to thank the participants
None of the authors have any conflicts of
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