Transcript Presentation
That Loving Feeling
by Snizhana Hostyanska, BS, CCRP North Kansas City Hospital Outpatient Cardiac & Pulmonary Rehabilitation
DISCLOSURES
No conflicts of interest (unfortunately
)
No non FDA approved or off label uses of medications will be discussed
You don’t have to be a “Sex Therapist” to help your patients and their
partner
.
You need to start the conversation!
Your patients want you to initiate the conversation. They want the permission that it’s okay to talk about this subject.
Sexual expression is an important part of our individual identity and yet, this area is rarely addressed by health care professionals Few patients report receiving counseling regarding the resumption of sexual activity.
Those who do receive counseling, restrictions are commonly given that are not supported by evidence or guidelines.
Doctors less likely to discuss sex with women patients than men .
TRIUMPH study ( 1184 men and 576 women) 46.3% of men and 34.5% of women reported receiving discharge instructions on resuming sexual activity.
40% of men and less than 20% of women talked about sex with their physicians in the year following heart event. Patients and their partners express a fear that sex could trigger another heart attack and such a loss of sexual activity can lead to depression and a reduced quality of life.
Becoming Comfortable with Intimacy topic
Know your own sexual attitude Have a knowledge base about sexual function and the physiological changes; medications; evidence based guidelines; lifestyle interventions.
Practice these discussions with colleagues.
Make sex a priority
Guidelines for Health Professional
Avoid overreaction / judgment Ensure privacy / confidentiality Refer patients to the specialist for complex problems.
Try PLISSIT model Remember! The more comfortable you are with the assessment, the more comfortable the patient will be.
PLISSIT Model
PLISSIT
is a model not an instrument or a tool!
P - Permission from the patient to initiate sexual discussion (it ’s core component of all ages!) LI – provide Limited Information needed to function sexually. (correct information, dispel myths ) SS- provide Specific Information to the patient to proceed with sexual relations.
IT- provide Intensive Therapy surrounding the issues of sexuality.
How to use PLISSIT Model
Ask open ended questions. Involve your patient’s partner. “In what way do your medications affect your sexual health ?” “Do you have any particular worries?” Understand your patients concerns and provide information about normal and pathologic age-related changes that can affect sexual health.
Misconception on aging and sexuality
It is necessary to be aware of your own sexual attitudes when addressing patients’ sexual health needs and avoid imposing personal judgments or making assumptions about individual patients’ needs: Older people aren’t sexy / attractive Older people shouldn't have sex My patient is too sick My patient is too frail to engage in sex Interest in sex is abnormal Patient is not married, or belong to a conservative religious group.
In case of sexuality – STEREOTYPES don’t work!
Physiological Responses during Sex
During foreplay BP & HR increases mildly More modest increase during sexual arousal The greatest increase occur during the 10-15 sec of orgasm.
Men and women have similar neuroendocrine, BP & HR responses to sexual activity.
Unfortunately, not every sexual experience is quite that…well, high intensity
.
Metabolic Demand “MODEST” Range of 3 to 4 METS • Climbing 2 flights of stairs • Walking briskly • NuStep level 2 • Bicycling light effort • General Housework / Light gardening
Cardiovascular Effect of Sexual Activity
HR rarely exceeds 130 bpm BP rarely exceeds 170 mmHg Is sex exercise ? Yes ! - For a short duration How long does MO & KS last?
Older patients may exert themselves to a greater degree / greater demand on their cardiovascular system.
Sexual Activity and Cardiovascular Risk
Coital Angina occurs during the minutes or hours after sexual activity. <5% all angina attacks.
Myocardial Infarction - <1% of all acute MIs. Sedentary individuals have higher risk of coital MI of 3.0. Physically active individuals risk of 1.2. Sexual Activity and Ventricular Arrhythmias/ Sudden Death – 0.6%-1.7% of sudden death related to sexual activity. Why? Individuals were having extramarital sex with a younger partner in an unfamiliar setting and/or after excessive food/alcohol consumption!
Exercise Training during Cardiac Rehabilitation.
Exercise training increases maximum exercise capacity and decreases peak coital HR.
Patients with unstable / decompensated heart disease: Unstable angina Decompensated HF Uncontrolled arrhythmia Significantly symptomatic/ severe valvular disease.
Sexual activity should be deferred until optimally managed.
When can I have Sex again?
Uncomplicated MI : >1 or more weeks(Class IIa; Level of Evidence C).
Previous MI: 3-4 weeks asymptomatic (3-5 METS) Post- PCI: several days after PCI CABG / Noncoronary Open Heart Surgery: 6 to 8 weeks, provided the sternotomy is well healed. Advise your patient to avoid positions that cause discomfort or put stress on the surgical site. HF : 60%-70% of HF pts report sexual problem.
When can I have Sex again?
ICD
is not a contradiction for sexual activity. Sexual activity often decreases after ICD implantations. Partner overprotectiveness and the fear of shock are important concerns for the patient and the partner. • • • Sexual activity should be deferred for patients with: Atrial fibrillation / poorly controlled ventricular rate Symptomatic supraventricular arrhythmia Exercise induced ventricular tachycardia.
Patient and spouse/partner counseling
Among partners of patients undergoing CR, sexual concerns were among the most prevalent stressors reported. Overprotection by family member is cited as a source of frustration, aggravation, fear, and anxiety. Women as partners report a great sense of loss and uncertainity, both emotional and sexual. Encourage patient-partner communication to address mutual concerns.
Screening Men with ED for Heart Disease could save lives!
(ED) has been tied to heart disease because the risk of both rises with : high BP, high LDL, diabetes, obesity and smoking. More than 18 million men in the U.S. have ED, more than eight million men have cardiovascular disease, and about two million have both. ED comes from dysfunction of the small arteries of the penis at the level of the blood vessels inner lining. Most men who have ED and cardiovascular disease start experiencing erectile dysfunction two to three years before a heart event!
Bring on the Pills!
Sexual dysfunction is a potential side effect of cardiovascular drugs particularly diuretic and β-blockers.
The majority of studies on sexual dysfunction induced by cardiovascular drugs relate to antihypertensive drugs. Most studies relate to male populations and only a few have been conducted on women.
Evidence to suggest that older antihypertensive drugs (diuretics & beta-blockers) have a negative impact on erectile function (ED), newer agents seem to have either neutral (ACE inhibitors, calcium antagonists) or beneficial effects (angiotensin receptor blockers, nebivolol)
Statins can perk up a man’s love life.
International Journal of Impotence Research, showed that only the men (an average age of 58) taking a statin saw a significant improvement in their condition (ED) by 25% Researchers think the cholesterol drug helps by increasing production of nitric oxide, which helps blood vessel walls relax and improves blood flow. In the pelvic area, this better blood flow would lead to improved erections.
Get back in the game!
PDE5 inhibitors
:
Levitra (Vardenafil), Viagra(Sildenafil), & Cialis (Tadalafil) Levitra & Viagra are short acting : ~4 hours Cialis is long acting :~ 17.5 hours Patients who are taking nitrates, such as nitroglycerin, should
NOT
use PDE5. Levitra & Cialis could result in hypotension. Tadalafil & Sildenafil approved for the Treatment of Pulmonary Arterial Hypertension: they improve exercise capacity and delayed clinical worsening. PDE5 should not be used for treating ED in patients with PH.
Get back in the game!
31 % of men who were prescribed ED medications discontinued use in 6 months. WHY?
• Adverse effect 5% • Cost of Drug 12% • Lack of desire for sex 45% • Lack of partner interest in sex 25% 64 % satisfied with the treatment
What you need to know about the king of male hormones.
In males, Leydig cells in the testes synthesize testosterone. In females, the ovaries and adrenal glands synthesize a much smaller amount of testosterone.
Male: 230-1000 ng/dL Female: 28-80 ng/dL One of testosterone’s major roles is to control muscle growth. Exercise can stimulate a short-term testosterone release, which may amplify muscle growth
Testosterone feedback loop in men
Several factors can suppress testosterone
chronically low calorie intake (>20% below basal needs)
and
chronically high calorie intake (especially if obesity results) low nutrient intake / vitamin/mineral deficiency, low fat intake Depression, stress and anxiety.
Limited sexual activity Aging Poor, minimal, and disrupted sleep (including obstructive sleep apnea)
Men and Women can suffer from low testosterone. Symptoms of low testosterone include:
low energy, fatigue, and lethargy — loss of “mojo” low sexual desire, lack of sexual responsiveness and weaker orgasms or difficulty achieving orgasm loss of lean body mass, including muscle and bone density, along with an increase in body fat especially visceral fat Men can experience hot flashes when testosterone suddenly drops, such as in prostate cancer treatment increased cardiovascular risk (including poor blood lipid profile), higher blood pressure.
Sleep apnea and hypogonadism
Sleep apnea is one cause of secondary hypogonadism.
Men with RLS (restless legs syndrome) were 78% more likely to have ED Arousal and erection are activated by the parasympathetic nervous system, which controls digestion and reproduction, too much stress, low O2 will lessen these functions.
Erectile dysfunction resolved in 17 of 42 men who used machines that maintain air flow throughout the night
Sleep Apnea Treatment might boost Sex Life
Excess weight can cause both low testosterone and sleep apnea.
1.
When someone complains of fatigue and loss of libido, there can be multiple reasons for this
. Many symptoms overlap and it is important to distinguish these.
2.
Just because your patient has low testosterone it doesn’t mean they need to take testosterone replacement
. There can be many underlying problems that once corrected can result in a normal testosterone
To maximize testosterone levels for muscle growth
Get on your feet. Sitting all day puts a lot of pressure on the prostate.
Make sure you are consuming enough micro and macronutrients Limit alcohol consumptions. Alcohol increases the conversion of testosterone to estrogen and increases inflammation in the area Engage in safe, regular sexual activity (yes, go get some action!) Get adequate sleep, 7-9 hours per night Control stress and anxiety levels.
What you should know about menopause
Ovaries produce estrogen, progesterone and androgens. They are signaled to do so by FSH (follicle stimulating hormone) and LH (luteinizing hormone) from the brain. With menopause, these hormones gradually decrease.
• • • • • There are many other physical and mental changes that can occur in midlife, which again reflect changes in both the physical environment (i.e. hormonal changes) and changes in your personal life (e.g. caregiving stress). This includes: changes in sex drive vaginal dryness; yeast infections and bladder infections changes in breast size (as estrogen declines) difficulty losing fat changes in appetite and/or food cravings
Changes in estrogen and progesterone during the life cycle
Hormone production
As ovarian hormone production declines, sex hormones secreted by body fat and other organs such as the adrenal glands become more prevalent. The balance tips.
It’s important to keep body fat in a healthy range with good nutrition and regular activity as we age. Having a lot of excess body fat puts hormone production out of whack and creates systemic inflammation. That just makes things worse.
Is Osphena the new female Viagra?
Osphena (ospemifene) is an oral medication that works like estrogen in the lining of the uterus. It approved by FDA (Feb 23 rd 2013) for painful sex due to vaginal dryness for menopausal females. 1in 3 women experience painful intercourse due to menopause 59% reported their enjoyment of sex was affected and 44% reported sex was painful.
Warning :
it might raise the risk of uterine cancer, blood clots and strokes. Common side effect HOT FLASHES!!!
HRT a Controversial Option
HRT can offset low hormone level in the body.
Natural Hormones
: substances identical to those produce in the body.
Synthetic Hormones:
chemically altered, but still similar Only natural progesterone seems to help prevent cancers, normalize blood fats, restore sex drive and regulate sleep. Synthetic progesterone can contribute to mood swings, fatigue, insomnia, bloating, weight gain, and anxiety.
HRT synthetic hormones
• • • • • •
HRT benefits
Relieves hot flashes Reduces insomnia Prevents vaginal dryness Decreases bone loss Reduces symptoms of arthritis Reduces chances of developing colorectal cancer • • • • • • •
HRT risks
Increases breast and uterine cancer Increases blood pressure Increases blood clots Increases gallbladder disease Withdrawal bleeding (when coming off HRT) Depression and agitation Fluid retention, bloating, nausea (not really “risks” – but definitely unwanted side effects)
HRT Cardiovascular disease
Naturally occurring estradiol is cardioprotective, however synthetic estrogen in HRT can lead to inflammation and blood clots.
Synthetic hormones increase risk of heart attack and stroke healthy women between the ages 50 and 59 do not have a higher risk of heart attack if they take estrogen or an estrogen/progesterone combination within the first 10 years of entering menopause. Starting HRT after the age of 60 is when the risk of heart attack and stroke increases.
Intimacy is the way of bonding
Women need to have sex! For themselves! So it is important to overcome the excuse of emotional disconnection and have sex with your husbands as frequently as possible. At least twice a week! It will allow BOTH partners to feel closer and create a more intimate context in which to resolve other issues
Depression : Your brain is your most important sex organ.
Anti-depressant/anti-anxiety medications are one of the most prescribed (and over-prescribed) classes of drugs in North America.
Depression is associated with poor compliance and increased health care costs Depression is highly prevalent in CHD patients Associated with worse outcomes The American Heart Association lists stress as a
possible
risk factor for heart attacks .
Marital Intimacy and Depression
Recent research has suggested that the absence of an intimate, confiding relationship may be a vulnerability factor in the development of depression in women.
There is a significant association between severity of depression and deficiencies of marital intimacy.
The body is constantly responding to its environment and making adjustments accordingly. If the environment is too stressful (no sleep, bad diet, lots of stress), the body compensates by declining the production of testosterone - and vice versa
Psychiatric Problems
The resultant depression may be an important contributing cause of ED in men and female sexual problems.
Anxiety disorders: Chronic or acute stress.
Personality disorders: obsessive-compulsive disorder Psychiatric disorders like schizophrenia or bipolar disorder Anxiety and depression regarding sexual activity should be assessed in patients with CVD
(Class I; Level of Evidence B)
.
Married Sex Gets better in the Golden Years
Relationship between martial characteristics and sexual outcome: 1,656 married adults ages 57-85 years. Researchers found the unexpected: those who passed the 50-year wedded mark began to report a slight increase in their sex life! Frequency in the sex lives of long-married couples continued to improve. Whether being married causes to have more sex or having more sex causes to stay married longer? Do they place intimacy as high priority?
Would you Chose TV over Sex?
The average American watches 34 hours of television a week.
Women 6 times more likely to choose a night of television over a night of sex.
1 in 10 said they couldn’t live without sex 1 in 5 said they couldn’t live without their favorite TV shows.
Take the TV out of your bedroom! Your bedroom is a place for sleep and sex only!
Bedroom is a no-technology zone!
Killing your sex drive one bite at a time.
The biggest culprit that knocks sex hormones out of balance is SUGAR!
• Sugar raises insulin and creates a hormonal domino effect. • Men with blood sugar imbalances have trouble getting and maintaining erections and often get “man boobs”
Killing your sex drive one bite at a time.
1.
Sugar lowers testosterone 2.
Sugar creates leptin resistance 3.
Sugar reduces growth hormone (GH) production. GH is “fountain of youth” & helps maintain optimal libido!
4.
Sugar makes you tired 5.
Sugar triggers stress and anxiety. Did you think how has sugar and processed food affect patients' libido or sex life?
The Importance of Timing
Arthritis
: your patient may find certain times of the day worse than others. Recommend to schedule lovemaking during one of the times arthritic pain is at its lowest ebb.
Recommend to Switch from night to morning sex.
Erections are usually better in the morning. Remember sex is a physical activity, and its better to have it when rested, and testosterone level tends to spike in the morning.
COPD and Sexuality
Sexual dysfunction and depression should be carefully questioned when recording the history of patients with COPD. Decreased exercise tolerance and fear of dyspnea may limit sexual activity. As well as low level of SaO2. Anxiety and depression are among the most common comorbidities in COPD.
COPD and Sexuality
Discuss pre sex preparation with your patients: • Take medications before sex ( about 15 min before sex) Short acting bronchodilator should be used in those with activity induced bronchoconstriction. • Use O2 if prescribed with activity.
• Energy Conservation Techniques (shorter kissing, relaxation, pacing) • Explore alternate sexual position
COPD and Sexuality
Use of PDE5 inhibitors might be appropriate for COPD patients Get a fan and clean the bedroom from lung irritants (dust, pet dander, smoke, fragrance, candles, scented deodorant, shampoo) Consider use of nasal irrigation and a mucus-loosening vibrating vest before sex.
Pick the right time Stay on track with exercise program.
Spicing up Sex Life
Touch each other daily!
Sexting each other during the day Getting erotic videos Sex toys The tie that binds (“Fifty Shades of Grey” anyone? )
Have I gone too far?
“Romance” is a verb
Take the time to tell your partner that they look wonderful, beautiful, sexy or great.
Make the time to hug and kiss each other for at least 10 seconds daily. Remember to touch your partner affectionately throughout the day, not just when you want to be romantic.
Plan a romantic date.
Intimacy does not equal SEX!