Sexual dysfunction in women with cardiovascular disease has received limited attention.1 Conversely, sexual dysfunction in men has received considerable awareness, particularly in the development of medications for treatment. Options for the management of erectile dysfunction are widely published in both professional literature and the lay media. While there are some therapeutic options for women, they are not well publicized. Compounding these disparities are myths and stereotypes regarding sexual function in women, with many health professionals and the public alike believing that women are not interested in sexual activity, particularly if they are postmenopausal. This article explores evidence-based literature related to sexual dysfunction in women and those with cardiovascular disease.
Although sexual function in women and men was explored in the early work of Masters and Johnson, particularly in defining sexual response, the view that sexual response is mainly a linear sequence of events focused primarily on genital organs does not tend to match the sexual experience for women.2 Subjective sexual arousal, including emotions and cognitions, appears to play a large role in female sexual response. In fact, the woman's experience with sexual arousal is not largely focused on lubrication, genital vasocongestion, and perception of swelling, contrary to common beliefs.2 Multiple factors influence the female sexual function and must be considered when assessing sexual function and dysfunction. This includes assessment of the couple, not just the woman.
Female Sexual Dysfunction in the General Population
There are several types of sexual dysfunction in women (Table 1), and an international committee of experts has defined these types based on available evidence.2 The most relevant definitions for the discussion in this article are highlighted. Women who experience sexual interest or desire disorder have diminished or absent feelings of sexual interest or desire and a loss of sexual thoughts or fantasies. Subjective sexual arousal disorder includes diminished or no feelings of sexual arousal, such as sexual excitement or pleasure, from any type of sexual stimulation. The woman may still have vaginal lubrication or other physical responses. In genital sexual arousal disorder, the woman may report impaired or absent genital arousal such as diminished vulvar swelling or vaginal lubrication despite sexual stimulation. Women may report sexual arousal or excitement, but a lack of orgasm or diminished intensity of orgasmic sensations or delay of orgasm, called orgasmic disorder. Some women have persistent difficulty with sexual intercourse. The 2 major reported problems are vaginismus and dyspareunia. Dyspareunia is when the woman experiences persistent or recurring pain with either an attempted or completed vaginal entry that occurs with or without penile-vaginal intercourse. Vaginismus is a persistent problem in which the woman has difficulty allowing vaginal entry of the penis, a finger, or other object, despite the desire to do so. There may be avoidance and fearfulness regarding the experience of pain, and this may be accompanied by involuntary pelvic muscle contraction.2,3 These definitions highlight the significant issues facing women with altered sexual response and the importance of a comprehensive assessment of the woman's sexual health, sexual function, and sexual dysfunction, taking into account physical, emotional, and psychological perspectives.
There has been some attention to the prevalence of female sexual dysfunction in the general population. Hayes et al4 analyzed the prevalence of female sexual dysfunction using a search strategy for research articles that identified the major categories of sexual dysfunction (desire, arousal, orgasm, pain). All 4 categories were required for each study reviewed, and a prevalence estimate was used. The authors excluded studies based on convenience sampling, a response rate less than 50%, sample size less than 100, or those studies where the sampling procedure was not clearly defined. Of the 1,248 publications reviewed, only 11 studies met the inclusion criteria. The averages across studies for female sexual dysfunction were 64%, problems with desire; 35%, orgasmic difficulty; 31%, arousal difficulty; 26%, and sexual pain. Of note, for those women who reported sexual difficulties that occurred for 1 month or more in the last year, 62% to 89% had sexual dysfunction that persisted for several months or more and 25% to 28% had sexual dysfunction that persisted for 6 months or longer.4 One limitation of this and of other studies is that prevalence is not consistently measured with the same instrument, thus limiting an appraisal of the true occurrence of sexual dysfunction in women. A recent study of sexual problems and distress in US women (n = 31,581) also revealed that the most common sexual problem was low desire, with an unadjusted prevalence of 38.7%.5 Other sexual problems included low arousal (26.1%), orgasmic difficulty (20.5%), and sexually related personal distress (22.8%). When stratified by age, the prevalence of any distressing sexual problems occurred more commonly in women aged 45 to 64 years (14.8%) than in those aged 65 years or older (8.9%) and 18 to 44 years (10.8%).5 In addition, poor health status and depression were associated with greater odds of orgasmic problems. These studies illustrate that although prevalence estimates may vary somewhat between studies, sexual dysfunction and the different subtypes are a significant health and wellness issue for many women, including younger women.
Factors that are associated with female sexual dysfunction were examined in a sample of 356 Australian women.6 Low desire has been associated with women in partnered relationships of 20 to 29 years in duration. Women who were perimenopausal, postmenopausal, or depressed were more likely to have low genital arousal. Sexual distress was positively linked with depression. Conversely, women with higher sexual desire tended to be those who reported more satisfaction with their partner as a lover or who placed greater importance on sexual activity. Low genital arousal was less likely to occur in women taking hormone therapy, those more educated, ages of 30s to 40s, or those who viewed sex as more important. Similarly, low orgasmic function was less likely for women in their 30s or those who placed a greater emphasis on sex.6 A longitudinal study of Australian women who were interviewed in year 11 (n = 257) revealed that although sexual function had declined significantly over the decade, women who used hormone therapy had greater sexual responsiveness and frequency of sexual activity, suggesting that hormone therapy may help maintain sexual function.7 Of the 17% of the sample with female sexual dysfunction, those with female sexual distress had greater depression scores, more negative feelings for their partner, and a lower total sex score.7 Both studies illustrate the importance of assessment of menopausal status and treatment, depression, and relationship factors. In addition, knowledge of sexual dysfunction in the general population can assist healthcare professionals in evaluating evidence related to sexual dysfunction in women with cardiovascular disease.
Mechanisms of Female Sexual Function and Dysfunction
An understanding of the vascular mechanisms that contribute to sexual function and dysfunction in women is particularly important, given the vascular nature of cardiac disease; however, the exact mechanisms in women continue to be studied. Important components of female sexual response include vaginal lubrication, clitoral erection, and orgasm. Clitoral engorgement in women is thought to be similar in mechanism to penile erection in men and may be an important component of female sexual dysfunction.1,8 Regulation of blood flow and clitoral erectile function appears to occur through the same nitric oxide-cyclic guanosine-monophosphate (cGMP) pathway. This neurovascular response to sexual arousal causes vasodilation in clitoral arteries and trabecular muscle relaxation, leading to sinusoid engorgement and dynamic venous obstruction.8 This is a localized response with increased vasodilation, particularly via nitric oxide, and diminished vasoconstriction; therefore, nitric oxide and cGMP play a key role in this response. In addition, subcellular pathways have been identified, and it is known that cGMP is controlled by "rapid degradation and inactivation of type 5 phosphodiesterase" (PDE5), as well as cGMP contributing to vasodilation by sequestration of calcium- and potassium-channel activation.8 Understanding of these pathways has led to the development of the PDE5 inhibitors as treatment for erectile dysfunction in men and beginning use of these medications in women.
In women with cardiovascular disease, atherosclerosis of the arterial bed that supplies the pelvic anatomy contributes to decreased vaginal engorgement and clitoral erectile insufficiency syndromes. Similar to men, female sexual dysfunction is caused by neuropathy or vascular disease related to cardiac risk factors such as diabetes, hypertension, smoking, or hyperlipidemia. It is thought that these conditions precipitate clitoral cavernosal ischemia, leading to fibrosis and smooth muscle loss in the clitoral cavernosal tissue and, consequently, female sexual dysfunction in those with cardiovascular disease.8 Neuropathic symptoms and female sexual dysfunction commonly occur in diabetes, and more than half of these women have reported orgasmic problems, and others reported decreased clitoral sensation.8 Not only is diabetes linked to cardiovascular disease in general, but a linkage may also exist between these diseases and female sexual dysfunction.
Age following menopause is an additional factor that has been linked to female sexual dysfunction. Decline in estrogen levels with age is a contributing factor. It is believed that estrogen increases vasodilation and engorgement by increased production of nitric oxide or activation of potassium channels, leading to clitoral or labial engorgement and vaginal lubrication.8 Postmenopausal women have reported improved sexual function with estrogen replacement therapy, particularly for orgasm, vaginal lubrication, and decreased pain with sexual intercourse. Although estrogen replacement therapy carries some risk of cardiovascular events, it may be the right choice for some women to maintain sexual function and control menopausal symptoms. Hormonal status is just one piece of the puzzle, however, and there are likely multiple contributors to female sexual dysfunction.9
In addition to these physiological factors, psychological factors may also play a role in female sexual dysfunction in women with cardiac disease. Anxiety, depression, or fear of a recurrent cardiac event may contribute to diminished libido in women. Therefore, assessments of both physiological and psychological factors are important considerations in female sexual dysfunction.
Female Sexual Dysfunction and Cardiovascular Disease
Sexual dysfunction has been primarily examined in women with coronary artery disease (CAD) and those with hypertension. Female sexual dysfunction has been described as "physically disconcerting, emotionally distressing, and socially disruptive" for many women,1(p326) thus highlighting the profound effect on both physical and psychological well-being.
Coronary Artery Disease
Kaya et al1 studied 20 women with CAD, diagnosed with angiography, compared with 15 matched women with no CAD. Those with CAD reported only 2.2 sexual intercourse episodes per month versus 5.2 episodes in women with no CAD (P < .05). Women with CAD were diagnosed more frequently as having female sexual dysfunction, including 12 women with CAD (60%) compared with 5 women with no CAD (33%). In addition, the Female Sexual Function Index score was significantly lower in CAD women (P = .001), and all domains of the scale (desire, arousal, lubrication, orgasm, pain) were significantly lower than those of the women with no CAD, with the exception of sexual satisfaction.1 Vaginal lubrication and orgasm were most affected in these women. Similarly, a larger study of Norwegian women revealed that 26% of women with heart disease and 11% of women in the general population reported sexual problems.10
Eyada and Atwa11 compared sexual activity in women with either non-ST-elevation myocardial infarction (MI) or unstable angina. About half of the patients (48.57%) had resumed sexual activity at the time of interview. Of these, 35% were not satisfied, 41% were mostly dissatisfied, and 24% were somewhat dissatisfied with their sexual relationship. For those not resuming sexual activity, 83% reported that sexual desire was much lower than prior to the cardiac illness. The authors noted greater depression (66.7%) and patient or partner fear of another MI (72.2%) or death during sexual intercourse (38.9%).11 Conversely, those patients who had attended cardiac rehabilitation were 3.77 times more likely to resume sexual activity compared with those who did not attend, thus highlighting the importance of education and support for return to sexual activity and prevention of some of the psychological impact that may contribute to sexual dysfunction.
The prevalence and correlates of sexual activity in 2,763 postmenopausal women with CAD and intact uteri were examined as part of the Medical Outcomes Study in the Heart and Estrogen/Progestin Replacement Study.12 Of the 39% of women who reported being sexually active, 65% reported at least one sexual problem that included lack of interest, inability to relax, difficulty with orgasm, problems with sexual arousal, or discomfort with sexual activity. Factors that were independently associated with sexual activity were a younger age, fewer years since menopause, being married, better self-reported health status, higher parity, moderate alcohol use, nonsmoking status, having no chest discomfort, and not being depressed. Those women who reported fewer sexual problems included those who were unmarried, better educated, better reported health status, and, interestingly, higher body mass index.12 Although many women with CAD continue to be sexually active, sexual problems do exist and need to be addressed.
Sexual satisfaction is another factor that has been shown to influence sexual function. Drory et al13 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, while better perceived health and higher education levels were positively associated with sexual satisfaction and sexual frequency. Similarly, McCall and colleagues14 found that 77% of women in their study were satisfied with sexual activity and tended to be older (opposite to the finding of Drory et al13) and with a higher income, better overall physical health, and fewer depressive symptoms. Sexual dissatisfaction was significantly associated with peripheral arterial disease (odds ratio, 1.44; 95% confidence interval, 1.15-1.82).14 A study comparing men and women before and after a coronary intervention revealed that whereas women were more sexually satisfied than men prior to the intervention (77% vs. 52%), at 8 years after intervention, women reported decline in sexual satisfaction when compared with men and prior to the intervention (70% vs 59%).15 Although sexual satisfaction and sexual activity were linked in these studies, little is known to what extent sexual satisfaction contributes to sexual dysfunction. A Norwegian study provides some beginning evidence related to these factors in individuals with acquired heart disease.16 In that study, those with low coital frequency were dissatisfied with that pattern, with 81% dissatisfied with no sexual activity and 62% dissatisfied with sexual frequency of once in the last 4 weeks. Overall, 71% of women were dissatisfied with coital frequency, and 65% reported current sexual dysfunction. When compared with men, the patterns of dissatisfaction and sexual dysfunction were similar. For women, 4 variables explained 43% of the variance in sexual dysfunction and were significant predictors of sexual dissatisfaction: conflicts with partner regarding sex, the importance of sex relative to sexual dissatisfaction, orgasm during sex, and fear of intercourse.16 One interesting observation by the author relative to sexual dissatisfaction and life satisfaction was that if sex was not perceived as important, the problem was likely to be solved. Conversely, if sex was perceived as important, the person was dissatisfied, although it would be difficult to achieve satisfaction in the presence of sexual dysfunction.16
Sexual satisfaction is a multifactorial construct and psychological stressors, and comorbid conditions likely play a role. In addition, sexual satisfaction may have different meanings for women versus men.14 Sexual satisfaction is known to be an important component related to sexual activity and one that needs further exploration as a contributing factor to sexual function and dysfunction.
Endothelial dysfunction has been linked with erectile dysfunction in men and is thought to contribute to female sexual dysfunction. The presence of endothelial dysfunction leads to increased clitoral collagen content8 and diminished genital blood flow and can result in both clitoral and vascular insufficiency, sometimes called vasculogenic female sexual dysfunction.17 Changes in pelvic blood flow affect the clitoral smooth muscle and the vagina, impair response to sexual stimulation, result in difficulty in achieving adequate vaginal lubrication, and affect sexual satisfaction. Nitric oxide is known to be impaired in essential hypertension, and women with chronic blood pressure elevations may experience female sexual dysfunction because of the effects on the nitric oxide pathway.17
A few studies have examined female sexual dysfunction in hypertension. Doumas et al17 compared 216 women with hypertension to 201 normotensive women. A greater number of women with hypertension had female sexual dysfunction (42.1%) than did normotensive women (19.4%).17 Both hypertensive and normotensive women had worsening of sexual dysfunction with increasing age. The duration of hypertension significantly affected sexual dysfunction in hypertensive women; the prevalence of sexual dysfunction for women with hypertension less than 3 years was 15.7%, 32.9% in those with hypertension for 3 to 6 years, and 78.6% in those with hypertension for more than 6 years.17 Besides age, increasing systolic blood pressure and β-blocker therapy were significant predictors of female sexual dysfunction. Adequate blood pressure control was shown to decrease the prevalence of sexual dysfunction, a finding that would be particularly relevant to include in patient education.
A study of Nigerian hypertensive women compared those who were newly diagnosed as having hypertension and treatment naive (n = 44), those previously diagnosed as having hypertension and on thiazide therapy (n = 29), and nonhypertensive women (n = 43).18 Among these groups, those who were newly diagnosed or previously diagnosed had more female sexual dysfunction (13.6% and 13.8%, respectively) than did the nonhypertensive women (4.7%). The authors note that antihypertensive medications can be a barrier to blood pressure control if sexual adverse effects are experienced and the medication discontinued by the patient. This illustrates the importance of assessing the woman's medication history, adverse effects, and barriers to adherence.
Burchardt and colleagues19 surveyed 67 hypertensive women to explore sexual activity, behavior, dysfunction, and satisfaction. Women had a mean age of 60 years, and 81.3% had a sexual partner. Sexual dysfunction was reported by 42.6% of the sample, with a mean duration of 3.9 (SD, 1.2) years. The reported sexual problems included anxiety or inhibition with sexual activity (48.7%), bleeding or irritation with sexual activity (30%), and lack of pleasure with sexual activity (61.8%).19 Interestingly, more than 50% of these women did not regularly engage in sexual activities, although more than one-third of the patients rated sexual activity as less than desired and more than half rated sexual activity as important. Perhaps of greater interest is that none of these women were offered treatment for sexual dysfunction, a finding that further amplifies the health professionals' responsibility to inquire about sexual issues and refer for appropriate treatment.
Sexual Dysfunction and Heart Failure
Reduced frequency of sexual activity and problems with sexual performance in heart failure are common, often due to heart failure symptoms, medication effects, comorbidities, and other factors. In general, most heart failure patients have reduced frequency of sexual activity, ranging from 48% to 76%, and 29.5% to 33% have ceased sexual activity.20-22 Slight or marked problems with sexual performance (44%-58.8%) have been reported, and some with heart failure are unable to perform sexually (20%-37%), many of them men.20-22
Schwarz et al23 examined the prevalence of sexual dysfunction among women and men with heart failure (N = 100). Of these, 87% of women were diagnosed as having female sexual dysfunction, and 84% of men were diagnosed as having erectile dysfunction. Reduced sexual desire was reported by 87% of women and 76% of men. Orgasmic problems were noted by 62% of women and 73% of men. Likewise, both women and men reported sexual dissatisfaction, 83% and 80%, respectively. Additional problems experienced by women were decreased vaginal lubrication (80%), decreased lubrication with pain (50%), and unsuccessful or interrupted intercourse (76%). Of note, 50% of women and 68% of men had sexual problems prior to the onset of heart failure; however, 29% of women and 43% of men reported a steady decline in sexual function over the last 6 months.23 These findings illustrate that preexisting sexual problems compounded by a diagnosis and treatment for heart failure can have a devastating effect on the sexual relationship. Of concern in this sample is that 75% of women and 60% of men stated that none of the physicians consulted in the last 3 years had inquired about sexual problems, again a call for health professionals to be mindful of sexual issues in practice.
Similar to those with hypertension, heart failure patients may experience sexual problems due to medications. In the recent study of the author and her colleagues, they24 found that the number of medications (P = .012), as opposed to medication class, significantly decreased the odds of being sexually active for those with heart failure. Other influencing factors decreasing the odds of sexual activity were tobacco use (P = .001), alcohol use (P = .016), and diabetes (P = .023). These 4 variables (medication, tobacco, alcohol, diabetes) accounted for 33% (R2 = 0.33) of the variance in sexual activity. Therefore, evaluation of the patient's medication plan and reducing unnecessary medications when possible would be important considerations in minimizing sexual dysfunction. Education about the control of cardiac risk factors as a means of enhancing sexual function would also be indicated.
Medications Contributing to Sexual Dysfunction
A variety of medications used to treat cardiovascular disease can contribute to sexual dysfunction, particularly those used for hypertension. This may lead the woman to choose between sexual quality of life and cardiovascular health.25 A few of the known findings related to women and sexual dysfunction are highlighted here; the reader can find a broader analysis of sexual adverse effects of medications in other sources.26 Adjusting medications to those with less sexual adverse effects may be indicated for some women, where possible. For example, angiotensin receptor blockers may improve sexual function, along with effective blood pressure control, and might be chosen instead of angiotensin-converting enzyme inhibitors.25 When using β-adrenergic blocking agents, β1 blockade tends to have less sexual impairment than does β2 blockade. Methyldopa is sometimes used for younger women as it is safe in pregnancy, but this drug disrupts sexual function due to central adrenergic inhibition. In a study comparing valsartan to atenolol in women, valsartan use resulted in improved sexual desire, sexual behavior, and sexual fantasies, whereas sexual desire and fantasies were worse in those women treated with atenolol.27 Thiazide diuretics have long been known to induce sexual adverse effects; therefore, a loop diuretic may be an effective substitution.25 For all patients, using the lowest effective medication dose may minimize sexual adverse effects and improve medication adherence.
Assessment and Management of Sexual Dysfunction in Women
As illustrated by the literature cited, women with cardiovascular disease have considerable informational needs. Also striking in the evidence reviewed is that sexual problems are prevalent in cross-cultural populations. In addition, many women wish to be sexually active, including those who are postmenopausal. Despite the sensitive nature of the topic, assessment of sexual concerns and problems and appropriate management are prime roles for healthcare professionals. An initial sexual assessment can be conducted by asking the woman a few quick questions as illustrated in Table 2. More formal assessments exist; however, these questions can be asked in a short amount of time and allow the nurse or physician to determine any problems to be addressed. For women with complex sexual issues, a referral to a sex counselor, a urologist, or other specialist may be indicated. In addition, there are several Web sites that have helpful information for women (Table 3).
A cornerstone in the management of female sexual dysfunction is risk factor management. This includes regular exercise, smoking cessation, blood pressure control, and diabetes control. In addition, encouraging women to attend cardiac rehabilitation, if appropriate, has been suggested as a way for women to get information and support.11
Medications Used to Manage Female Sexual Dysfunction
A variety of medications have been suggested for the treatment of female sexual dysfunction. Estrogen therapy, if not contraindicated, can improve sexual function in some women. Transdermal estrogen therapy may be used in place of oral therapy, with evaluation in 3 months for improvement in sexual desire.8,28 Tibilone is a selective estrogenic activity regulator that is metabolized in the gastrointestinal tract. It has been shown to be effective for some postmenopausal with estrogen deficiency syndrome (it is contraindicated in premenopausal women). Tibilone may improve sexual function, sexual desire, and sexual arousal, although it has been studied primarily in healthy postmenopausal women.28 A trial of tibilone is suggested before treatment with testosterone therapy.
Androgen therapy, such as testosterone, may enhance libido and vasodilation through nitric oxide synthesis, but it has not been approved by the Food and Drug Administration for female sexual dysfunction, and androgen therapy does have some increased cardiac risk.8 A transdermal testosterone patch has been approved in Europe for estrogen-treated, surgically postmenopausal women with hypoactive sexual desire disorder.28 Studies to date suggest an increased number of sexually satisfying events when testosterone was used in postmenopausal women. Testosterone use in women without insulin resistance does not appear to increase cardiac risk.28
The PDE5 inhibitors were first developed for men with erectile dysfunction, and studies now suggest that these medications may be useful in women with genital arousal disorder, but not those with low desire and subjective arousal disorder.28 Type 5 phosphodiesterase expression has been identified in the vagina and clitoris; therefore, the nitric oxide-PDE5 axis is then targeted in therapy. In fact, some have suggested that topical nitroglycerin might be an option for dyspareunia because of its vasodilatory effect. Type 5 phosphodiesterase inhibitor use in women with female sexual dysfunction is controversial. In animal models, PDE5 inhibitors have improved clitoral function and by similar mechanisms of actions as in the male penis.8
Sildenafil has been reported to improve physiological responses to sexual stimulation, increased vaginal lubrication, and clitoral sensation, particularly in women with sexual desire disorder.8,28 Sildenafil may also be useful to treat sexual adverse effects from antidepressant therapy.8 Adverse effects of PDE5 inhibitors in women include increased heart rate and blood pressure. It is thought that women with type 1 diabetes mellitus might also benefit from the PDE5 inhibitors, although further study is needed. There is no current evidence-based therapy for women with cardiovascular disease. Therefore, careful evaluation of women with hypertension, dyslipidemia, diabetes, and CAD is warranted before a trial of sildenafil.8,28
Implications for Practice
Nurses can play a key role by routinely assessing sexual function, comorbidities, and use of medications, particularly those with sexual adverse effects. An open discussion of sexual concerns for women with cardiovascular disease is paramount, as the woman may need encouragement to seek treatment. Addressing sexual fears related to sexual activity is an important component as noted in the literature reviewed.11,16 In addition, available and emerging treatment options for female sexual dysfunction should be discussed with both the woman and her partner. The quality of life of the woman with sexual dysfunction and cardiovascular disease can be enhanced only when the healthcare team takes a proactive role in the assessment of sexual function and management of sexual dysfunction.
Sexual function in women is significantly affected by CAD, and further research is needed to fully understand the mechanisms for sexual dysfunction and viable treatment options. Specifically, research is needed with consistent measures for female sexual dysfunction, accurate estimates of female sexual dysfunction in those with cardiovascular disease, and randomized controlled trials of women with CAD, MI, hypertension, heart failure, and diabetes.17 A thorough evaluation of therapies for female sexual dysfunction in those with cardiovascular disease is warranted.
1. Kaya C, Yilmaz G, Nurkalem Z, Ilktac A, Karaman M. Sexual function in women with coronary artery disease
: a preliminary study. Int J Impot Res
2. Basson R, Leiblum S, Brotto L, et al. Revised definitions of women's sexual dysfunction
. J Sex Med
3. Binik YM, Reissing E, Pukall C, Flory N, Payne KA, Khalife S. The female sexual pain disorders: genital pain or sexual dysfunction
. Arch Sex Behav
4. Hayes RD, Bennett CM, Fairley CK, Dennerstein L. What can prevalence studies tell us about female sexual difficulty and dysfunction. Int Soc Sex Med
5. Shifren J, Monz B, Russo P, Segreti A, Johannes C. Sexual problems and distress in United States women. Obstet Gynecol
6. Hayes R, Dennerstein L, Bennett C, Sidat M, Gurrin L, Fairley C. Risk factors for female sexual dysfunction
in the general population: exploring factors associated with low sexual function and sexual distress. J Sex Med
7. Dennerstein L, Guthrie J, Hayes R, DeRogatis L, Lehert P. Sexual function, dysfunction, and sexual distress in a prospective, population-based sample of mid-aged, Australian-born women. J Sex Med
8. Archer SL, Gragasin FS, Webster L, Bochinski D, Michelakis E. Aetiology and management of male erectile dysfunction and female sexual dysfunction
in patients with cardiovascular disease
. Drugs Aging
9. Dennerstein L, Lehert P, Burger H, Dudley E. Factors affecting sexual functioning of women in the mid-life years. Climacteric
10. Traeen T, Olsen S. Sexual dysfunction
and sexual well being in people with heart disease. Sexual and Relationship Therapy
11. Eyada M, Atwa M. Sexual function in female patients with unstable angina or non-ST elevation myocardial infarction. J Sex Med
12. Addis I, Ireland C, Vittinghoff E, Lin F, Stuenkel C, Hulley S. Sexual activity and function in postmenopausl women with heart disease. Obstet Gynecol
13. Drory Y, Kravetz S, Weingarten M. Comparison of sexual activity of women and men after a first myocardial infarction. American Journal of Cardiology
14. McCall J, Freund K, Legault C, et al. Sexual satisfaction and cardiovascular disease
: the Women's Health Initiative. The American Journal of Medicine
15. Lukkarinen H, Lukkarinen O. Sexual satisfaction among patients after coronary bypass surgery or percutaneous transluminal angioplasty: eight year follow-up. Heart & Lung
16. Traeen T. Sexual dissatisfaction among men and women with congenital and acquired heart disease. Sex Relat Ther
17. Doumas M, Tsiodras S, Tsakiris A, et al. Female sexual dysfunction
in essential hypertension
: a common problem being uncovered. J Hypertens
18. Okeahialam BN, Obeka NC, Abakaliki J. Sexual dysfunction
in female hypertensives. J Natl Med Assoc
19. Burchardt M, Burchardt T, Anastasiadis A, et al. Sexual dysfunction
is common and overlooked in female patients with hypertension
. J Sex Marital Ther
20. Jaarsma T, Dracup K, Walden J, Stevenson L. Sexual function in patients with advanced heart failure
. Heart Lung
21. Jaarsma T. Sexual problems in heart failure
patients. Eur J Cardiovasc Nurs
22. Westlake C, Dracup K, Walden J, Fonarow G. Sexuality of patients with advanced heart failure
and their spouses or partners. J Heart Lung Transplant
23. Schwarz E, Kapur V, Bionat S, Rastogi S, Gupta R, Rosanio S. The prevalence and clinical relevance of sexual dysfunction
in women and men with chronic heart failure
. Int J Impot Res
24. Steinke EE, Mosack V, Wright DW, Chung ML, Moser DK. Risk factors as predictors of sexual activity in heart failure
. Dimens Crit Care Nurs
25. Clayton A, Ramamurthy S. The impact of physical illness on sexual dysfunction
. Adv Psychosom Med
26. Steinke E, Jaarsma T. Impact of cardiovascular disease
on sexuality. In: Moser D, Riegel B, eds. Cardiac Nursing: A Companion to Braunwald's Heart Disease
. Philadelphia, PA: Elsevier Saunders; 2008:241-253.
27. Fogari R, Preti P, Zoppi A, et al. Effect of valsartan and atenolol on sexual behavior in hypertensive postmenopausal women. Am J Hypertens
28. Davis SR, Nijland EA. Pharmacological therapy for female sexual dysfunction
29. McKinney LN. Low libido in postmenopausal women. Adv Nurse Pract
Keywords:© 2010 Lippincott Williams & Wilkins, Inc.
cardiovascular disease; coronary artery disease; female sexual dysfunction; heart failure; hypertension; medications; sexual dysfunction