The development of erectile dysfunction (ED) in men has been shown to predict subsequent cardiovascular disease (CVD) with an effect similar to or greater than factors such as a family history of MI, hypertension or an adverse lipid profile.
It has therefore been argued that reported onset of ED should trigger review of cardiovascular risk markers and aggressive treatment. It is not known whether such treatment will improve sexual performance as well as it reduces cardiovascular morbidity. The corollary – that treatment of ED may improve cardiovascular outcome – is similarly unknown.
Studies of the control arm of the Prostate Cancer Prevention Trial first reported this link.1 It was important for this study to exclude hypo-androgenicity as the common factor. Researchers found that reduced libido only occurred in 1 per cent of the men before the development of ED. Vascular compromise therefore appeared to be the common cause.
CVD in women
In women, there is increasing evidence to support the observation that CVD presentation and its risk markers are different. Sexual functioning is also different.
Studies of sildenafil have been much less successful in women. This is not surprising if genital engorgement is not the sentinel requirement for sexual satisfaction. Relationship issues, external stresses (family, financial, employment), fatigue, unhappiness with body shape and features, lack of opportunity and discomfort resulting from urogenital atrophy can all have a significant impact. Hypo-androgenicity in women may present as a loss of sexual desire and interest, but all other issues should be explored sensitively before determining this to be the cause.
It is most often identified after bilateral oophorectomy because this is associated with more than 50 per cent reduction in androgen production. Testosterone levels in women naturally decline throughout life, with no menopause-associated drop.
Lack of sexual satisfaction is more readily reported by women than in the past, but there is still a high level of reticence. It may need to be sought out by the use of open questions, using language that is understood by the woman but not offensive. Women no longer feel this is something they have to put up with and many mourn the loss of previous sexual activity and response. It has been estimated that loss of sexual satisfaction can have an adverse impact on women's quality of life similar to that of ED in men.
The clinician can make many practical suggestions regarding management of time and opportunity, and advising about positions and lubricants to make things more comfortable. Topical oestrogens to reverse atrophic change can make a significant difference within weeks and improvement will continue over subsequent months. Inclination and enjoyment often return when penetration is no longer painful. Systemic hormone replacement may be appropriate.
Acknowledging relationship issues can be a crucial step and may enable the couple to discuss these or act as the preliminary to a referral for psychosexual or relationship counselling.
The Prostate Cancer Prevention Trial studied men aged 40-70 in the US. These men would rarely have attended for routine screening if they had not been part of the trial. In the US, 40 per cent of men die of CVD and 50 per cent of CHD deaths have no previous cardiovascular history. The development of ED might reasonably be used as a predictor of disease. Does presentation of sexual dissatisfaction in women predict cardiovascular risk, as ED would in men? Intuitively, the answer would be no.
The Women's Health Initiative investigators have recently published findings from their observational arm that have failed to show a link between sexual dissatisfaction and CVD in women.2 This study is not as robust as the prostate study and there are a number of factors that should be appreciated.
The sexual satisfaction questionnaire that they used had not been formally validated and addresses a global rather than a specific domain. Responses were only analysed from those who reported sexual activity with another person in the previous year and who completed that element of the questionnaire at study entry. No subsequent questioning was carried out.
This is in marked contrast to the prostate study, which excluded existing ED and only considered incident problems. Sexual satisfaction was associated with better overall health, fewer depressive symptoms, higher family income, more physical activity, never smoking and a normal BMI.
No association was found between levels of satisfaction and hypertension, family history of MI, hyperlipidaemia, diabetes and use of HRT at baseline. Sexual dissatisfaction was associated with peripheral vascular disease, but the baseline survey does not mean this is predictive. There was no association with MI, stroke, revascularisation, heart failure or a composite measure.
This is an important negative finding. Science has reinforced common sense. Women are different and sexual functioning is complicated. CVD aetiology and presentation are not the same as for men. Mid-life should be the trigger for cardiovascular risk analysis, healthy lifestyle advice and risk modification if indicated. It should also be a trigger to enquire sensitively about sexual function, recognising that it does impact on quality of life and intervention can be simple and effective.
- Dr Sarah Gray is a GPSI in women's health in Truro, Cornwall.
1. Thompson IM, Tangen CM, Goodman PJ et al. Erectile dysfunction and subsequent cardiovascular disease. JAMA 2005; 294: 2996-3002.
2. McCall-Hosenfeld JS, Freund KM, Legault C et al. Sexual satisfaction and cardiovascular disease: the Women's Health Initiative. Am J Med 2008; 121; 295-301.