| | Sexual Satisfaction and Cardiovascular Disease: The Women’s Health InitiativePreliminary results from this work were presented at the Society of General Internal Medicine 30th Annual Meeting, Toronto, Ontario, Canada, April 26, 2007. Abstract BackgroundSexual dysfunction in some men is predictive of occult cardiovascular disease. We investigated whether dissatisfaction with sexual activity, a domain of female sexual dysfunction, is associated with prevalent and incident cardiovascular disease in postmenopausal women. MethodsData from the Women′s Health Initiative-Observational Study were used. Subjects who were sexually active in the past year were classified at baseline as sexually satisfied or dissatisfied. We performed multiple logistic regression analyses modeling baseline cardiovascular conditions including myocardial infarction, stroke, coronary revascularization, peripheral arterial disease, congestive heart failure, and angina. We then created Cox proportional hazards models to determine hazard ratios for incident cardiovascular disease by baseline sexual dissatisfaction status. ResultsDissatisfaction with sexual activity at baseline was significantly associated with prevalent peripheral arterial disease (odds ratio 1.44, 95% confidence interval, 1.15-1.84), but not prevalent myocardial infarction, stroke, coronary revascularization including coronary artery bypass graft and percutaneous transluminal coronary angioplasty, or a composite cardiovascular disease variable. The odds of baseline angina were decreased among those reporting sexual dissatisfaction at baseline (odds ratio 0.77, 95% confidence interval, 0.66-0.86). In both unadjusted and adjusted analyses, dissatisfaction with sexual activity was not significantly related to an increased hazard of any cardiovascular disease. ConclusionsDissatisfaction with sexual activity was modestly associated with an increased prevalence of peripheral arterial disease, even after controlling for smoking status. However, dissatisfaction did not predict incident cardiovascular disease. Although this may represent insensitivity of the sexual satisfaction construct to measure sexual dysfunction in women, it might be due to physiological differences in sexual functioning between men and women. Female sexual dysfunction is a prevalent, distressing condition, affecting 43% of the population.1 Although it has been linked to a higher burden of medical illnesses, specific underlying causes are not well described. One potential candidate is cardiovascular disease. The association of cardiovascular disease with male sexual dysfunction is well documented.2 Erectile dysfunction is one manifestation of subclinical cardiovascular disease and is a marker for the development of subsequent cardiovascular disease in some men.3 Clinical Significance•Sexual dysfunction in some men is predictive of cardiovascular disease, but this association has never been examined in women. •We found no increased prevalence or incidence of cardiovascular disease among sexually active female subjects complaining of dissatisfaction with sexual activity at baseline, over 7.8 years of follow-up. •Physiological differences between men and women may explain the difference in the role of cardiovascular disease in sexual function. Basic science and human research suggests that the vascular pathophysiology of male and female sexual dysfunction is similar.4, 5, 6 The regulation of blood flow and clitoral erectile function is governed by the same nitric oxide-cyclic guanosine monophosphate (GMP) pathway in women as erectile function is in men.4, 7 Atherosclerosis of the arterial bed supplying female pelvic anatomy can lead to decreased vaginal engorgement and clitoral erectile insufficiency syndromes,6 similar to erectile problems in men. Chronic atherosclerotic disease in animal models can cause significant disease of the vagina.8 To date, the association of cardiovascular disease with female sexual dysfunction has not been explored. Specifically, it has never been shown that subclinical cardiovascular disease impacts female sexual functioning significantly enough to affect sexual satisfaction. Current survey instruments9, 10, 11 divide female sexual function into several unique domains, including sexual satisfaction. The International Consensus Development Conference on Female Sexual Dysfunction highlighted personal distress as a necessary element and noted that patient self-report is the preferred method of determining sexual dysfunction in women.12 Thus, female sexual dysfunction can be measured as self-reported dissatisfaction with sexual activity. Concordantly, sexual satisfaction is an important domain of sexual functioning in women. The objectives of this study were: to explore the association of sexual satisfaction with prevalent cardiovascular disease and cardiovascular disease risk factors among sexually active postmenopausal women, and to determine if low sexual satisfaction, a domain of female sexual functioning, is predictive of incident cardiovascular disease in women, using the Observational Study cohort of the Women’s Health Initiative. Materials and Methods  Subjects Data from the Women’s Health Initiative Observational Study (WHI-OS) were used. Details of recruitment and eligibility screening in the WHI-OS have been described elsewhere.13 Participants were postmenopausal women aged 50 to 79 years, recruited at 40 clinical centers throughout the United States during 1994 through 1998. There were 93,676 women who participated in the observational cohort14, 15 and were followed for 8-12 years. Institutional review boards approved the study at all participating sites. Data Collection Data on sexual satisfaction and baseline cardiovascular disease were collected during one or more initial screening visits. Thereafter, follow-up medical histories of the participants were identified via annual surveys and verification of outcomes. The details of the methodologies used for ascertaining, classifying, and documenting outcomes have been described previously.16 Each annual follow-up survey with a positive response for cardiovascular disease prompted a review and abstraction of the medical record for that patient. Key outcomes, including cardiovascular disease, were adjudicated by centrally trained WHI physician adjudicators at each clinical center.16 Of note, follow-up data on sexual satisfaction were not available. Women who indicated at baseline that they did not want to answer the sexual satisfaction question, and those with missing data for this item were excluded from analyses. To isolate medical rather than social etiologies of sexual satisfaction, subjects who reported no sexual activity with a partner in the last year also were excluded. Definition of Variables Satisfaction with current sexual activity was assessed by a single survey item categorized along a 4-point Likert-type scale, “How satisfied are you with your current sexual activities, either with a partner or alone?” (1 =very unsatisfied, 2=a little unsatisfied, 3=somewhat satisfied, 4=very satisfied). After qualitatively assessing the response variables to ensure similar direction between extreme variables and nearest middle range response, the responses were dichotomized into satisfied (responses 3 and 4) versus unsatisfied (responses 1 and 2) to simplify analysis. The presence of cardiovascular disease at baseline was defined as a self-reported history of acute myocardial infarction, stroke, or coronary revascularization procedure (coronary artery bypass graft or percutaneous transluminal coronary angioplasty). Related cardiovascular problems, including congestive heart failure, peripheral arterial disease, and angina also were examined. Covariates included cardiovascular disease risk factors and mitigants including physical activity, smoking status, hypertension, family history of myocardial infarction, high cholesterol requiring pills, beta-blocker use, diabetes, and body mass index (BMI). Covariates included health-related factors that might affect sexual functioning. Overall health-related quality of life was measured using the general health subscale of the SF-36 (scores range from 0-100 with a higher score indicating a more favorable health state).17 Current depressive symptoms were measured using an 8-item scale designed to screen for depressive disorders,18 composed of 2 items from the Center for Epidemiologic Studies Depression Scale19 and 2 items from the Diagnostic Interview Schedule.20 Higher scores on this scale indicate more severe depression. Other health-related conditions included as covariates in models were a history of cervical, ovarian, or endometrial cancer, a history of hysterectomy, and parity, all measured by patient self-report at baseline. Medications including oral contraceptive use ever, hormone replacement therapy use at baseline, and selective serotonin reuptake inhibitor (SSRI) use also were examined. Demographic covariates included race and ethnicity, marital status, family income, education, employment status, and sexual orientation, all determined by patient self-report from the baseline questionnaires. For prospective analyses, fatal and nonfatal incident cardiovascular disease in the WHI-OS cohort were defined as incident acute myocardial infarction, coronary death, stroke, or coronary revascularization that occurred during follow-up. Related incident diseases, including congestive heart failure, peripheral arterial disease, and angina also were examined. Subjects who reported prevalent cardiovascular disease or related illnesses at baseline were excluded from analyses of prospective data. Statistical Analysis To determine the association between sexual satisfaction and baseline cardiovascular conditions, logistic regression models examining each of the baseline cardiovascular conditions (myocardial infarction, stroke, coronary revascularization, and a composite endpoint including each of the above, peripheral arterial disease, angina, and congestive heart failure) were developed. These models included demographic variables, baseline medical conditions, and cardiovascular disease risk factors that were significantly associated with sexual satisfaction or cardiovascular disease in bivariate analyses. Backwards and stepwise selection procedures were utilized, with both 0.05 and 0.20 selected as entry and retention criteria. With backwards selection, the initial model includes all variables, which are then deleted from the model one at a time until all the variables remaining in the model meet the retention criteria. With stepwise selection, variables are entered one by one to the model based on the entry criterion. At each step, any of the variables in the model that does not meet the retention criterion is deleted. The lists of variables in the final models did not change under these different assumptions. After creating these final models for each cardiovascular outcome, sexual satisfaction status was included in the models. To determine whether sexual satisfaction at baseline was associated with incident cardiovascular disease, variables significant at the 0.05 level in bivariate analyses, as well as clinically important variables related to cardiovascular disease, were fitted into Cox proportional hazards model, with time to incident cardiovascular disease as the response variable. As in the prevalence analysis, variables were retained in the models if they met a prespecified retention criterion of 0.05. Hazard ratios and their respective confidence intervals are reported. Results Baseline characteristics of the WHI-OS participants have been described elsewhere.13 Fifty-two percent (48,300) of these women reported that they had been sexually active with another person in the past year. Of these, 96% (46,525) answered the sexual satisfaction question. Overall, 77% (35,719) of respondents reported satisfaction with sexual activity. Women who reported that they were satisfied sexually were older and had higher family incomes than women who reported that they were not satisfied sexually (Table 1). Sexual satisfaction also was associated with better overall physical health and fewer current depressive symptoms. | | |  | | Satisfied Sexually (n = 35,719) | Not Satisfied Sexually (n = 10,806) | |
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| n | % | n | % | |
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| Categorical variables | | | | | | | Age (years)⁎ | | | | | | | 50-59 | 14,741 | 41% | 4906 | 45% | | | 60-69 | 15,673 | 44% | 4513 | 42% | | | 70-79 | 5305 | 15% | 1387 | 13% | | | Race/ethnicity⁎ | | | | | | | White | 30,629 | 86% | 9325 | 86% | | | Black | 2269 | 6% | 776 | 7% | | | Hispanic | 1252 | 4% | 385 | 4% | | | Other | 1490 | 4% | 299 | 3% | | | Marital status⁎ | | | | | | | Never married | 345 | 1% | 161 | 1% | | | Divorced/separated | 2632 | 7% | 1295 | 12% | | | Widowed | 1508 | 4% | 580 | 5% | | | Married/partnered | 31,083 | 87% | 8720 | 81% | | | Family income⁎ | | | | | | | <$10,000-19,999 | 2321 | 7% | 874 | 9% | | | $20,000-$49,999 | 12,571 | 38% | 3992 | 39% | | | $50,000-74,999 | 8221 | 25% | 2476 | 24% | | | $75,000+ | 10,191 | 31% | 2782 | 27% | | | Measurement variables | Mean | (SD) | Mean | (SD) | | | Depression score⁎† | 0.03 | 0.10 | 0.06 | 0.15 | | | Overall health⁎‡ | 76 | 17 | 74 | 19 | | | | |
| ⁎ P <.001. †Scale: −8.2-4.0. Higher scores indicate more severe depressive symptoms. ‡Scale: 0-100. Higher scores indicate better general health. |
Satisfaction with sexual activity, compared with dissatisfaction, was modestly associated with several cardiovascular disease risk factors, including more physical activity, never smoking, and normal BMI (Table 2). A slightly higher proportion of subjects on beta-blockers at baseline reported dissatisfaction with sexual activity, but this difference was minimal. No association was found between sexual satisfaction and other cardiovascular disease risk factors, including hypertension, menopausal hormone therapy, diabetes, family history of myocardial infarction, and hyperlipidemia. | | | | CVD Risk Factor | Satisfied Sexually (n = 35,719) | Not Satisfied Sexually (n = 10,806) | |
|---|
| Exercise⁎ | | | | | | | Little or no activity | 16,242 | 46% | 5134 | 48% | | | 2 or more times per week | 19,167 | 54% | 5595 | 52% | | | Smoking⁎ | | | | | | | Never smoked | 18,897 | 53% | 5208 | 49% | | | Past smoker | 14,616 | 41% | 4813 | 45% | | | Current smoker | 1825 | 5% | 654 | 6% | | | Body mass index⁎ | | | | | | | <18.5 Underweight | 349 | 1% | 122 | 1% | | | 18.5-24.9 Normal | 15,583 | 37% | 4565 | 35% | | | 25.0-29.9 Overweight | 12,096 | 28% | 3657 | 28% | | | ≥30 Obesity | 7301 | 17% | 2343 | 18% | | | Hypertension (P=.31) | | | | | | | Never hypertensive | 25,007 | 71% | 7522 | 71% | | | Treated hypertensive | 7697 | 22% | 2331 | 22% | | | Untreated hypertensive | 2497 | 7% | 794 | 7% | | | Baseline hormone replacement therapy use (P=.13) | 15,572 | 44% | 4800 | 44% | | | Diabetes (P=.17) | 1470 | 4% | 477 | 4% | | | Family history of myocardial infarction (P=.19) | 4821 | 28% | 1533 | 29% | | | Treated hyperlipidemia (P=.12) | 4513 | 13% | 1427 | 13% | | | Beta-blocker use† | 1602 | 4.5% | 533 | 5.0% | | | | |
In logistic regression modeling, dissatisfaction with sexual activity was significantly associated with prevalent peripheral arterial disease (odds ratio 1.44, 95% confidence interval, 1.15-1.82; Table 3). The odds of prevalent angina were lower among those reporting sexual dissatisfaction (odds ratio 0.77, 95% confidence interval, 0.66-0.90, P <0.001). Sexual dissatisfaction at baseline was not significantly associated with prevalent myocardial infarction, stroke, coronary revascularization, the composite cardiovascular disease variable, or congestive heart failure. | ⁎ Myocardial infarction model variables removed: race/ethnicity, marital status, family income, sexual orientation, history of cervical, ovarian, or endometrial cancer, history of hysterectomy, OC use ever, baseline HRT usage, SSRI use, exercise, BMI. †Stroke model variables removed: race/ethnicity, marital status, family income, education, sexual orientation, history of cervical, ovarian, or endometrial cancer, parity, OC use ever, baseline HRT usage, SSRI use, exercise, family history of myocardial infarction, BMI. ‡Coronary revascularization model variables removed: race/ethnicity, marital status, family income, employment status, sexual orientation, depression score (continuous), history of cervical, ovarian, or endometrial cancer, history of hysterectomy, parity, OC use ever, baseline HRT usage, SSRI use, exercise, BMI. §Composite cardiovascular disease model variables removed: race/ethnicity, marital status, family income, sexual orientation, history of cervical, ovarian, or endometrial cancer, parity, OC use ever, baseline HRT usage, SSRI use, exercise, BMI. ∥Peripheral arterial disease model variables removed: race/ethnicity, marital status, family income, employment status, sexual orientation, history of cervical, ovarian, or endometrial cancer, OC use, exercise. ¶Angina model variables removed: race/ethnicity, marital status, family income, employment status, history of cervical, ovarian, or endometrial cancer, parity, OC use ever, exercise. ⁎⁎CHF model variables removed: race/ethnicity, marital status, family income, education, sexual orientation, history of cervical, ovarian, or endometrial cancer, history of hysterectomy, parity, OC use ever, baseline HRT usage, SSRI use, BMI. |
To determine if women with cardiovascular disease abstained from sexual activity, an interaction term between levels of reported sexual activity in the past year and sexual satisfaction was included in each of the models. Level of sexual activity in the past year was defined as any versus none. If significant, the interaction term would suggest that the association between sexual satisfaction and cardiovascular outcome differed between those with reported sexual activity and those with no reported sexual activity in the past year. This interaction term was not significant in any model, thus, exclusion of those who were not sexually active due to cardiovascular disease was unlikely to explain our negative findings. To determine whether our results were confounded by the exclusion of women who abstained from sexual activity because of cardiovascular disease and its symptoms and were dissatisfied because of this, we assessed whether subjects worried that sexual activity would affect their health. Worry that sexual activity would affect their health showed little difference between sexually satisfied and dissatisfied subjects. Similar percentages of both the satisfied (99%) and dissatisfied (96%) respondents were either not at all worried, or only a little worried. Thus, dissatisfaction with sexual activity due to fear of cardiovascular health-related consequences is an unlikely explanation for these findings. To determine if inclusion of cardiovascular risk factors over-adjusted the regression models, a separate series of regressions models excluding the cardiovascular disease risk factors were performed and no significant changes in overall results were found. For our prospective analyses, subjects were followed for an average of 7.8±1.4 years. In unadjusted and adjusted analyses of follow-up data, no increased incidence or hazard of cardiovascular disease among sexually satisfied versus dissatisfied participants was found (Table 4). No changes in these results were found when cardiovascular risk factors were excluded from the models. | ⁎ Total cardiovascular disease model variables removed: race/ethnicity, marital status, education, employment status, sexual orientation, depression score, history of cervical, ovarian, or endometrial cancer, history of hysterectomy, parity, oral contraceptive (OC) use ever, baseline HRT use, SSRI use, exercise, BMI. †Myocardial infarction model variables removed: marital status, education, employment status, sexual orientation, depression score, history of cervical, ovarian, or endometrial cancer, history of hysterectomy, OC use ever, baseline HRT use, SSRI use, exercise, family history of myocardial infarction, BMI. ‡Coronary revascularization model variables removed: race/ethnicity, marital status, employment status, sexual orientation, depression score, history of cervical, ovarian, or endometrial cancer, history of hysterectomy, OC use ever, baseline HRT use, SSRI use, exercise, BMI. §Stroke model variables removed: race/ethnicity, marital status, family income, education, employment status, sexual orientation, depression score, SF-36 subscale (overall health), history of hysterectomy, parity, OC use ever, baseline HRT use, SSRI use, exercise, family history of myocardial infarction, BMI. ∥Peripheral arterial disease model variables removed: race/ethnicity, marital status, family income, employment status, sexual orientation, depression score, SF-36 subscale (overall health), history of cervical, ovarian, or endometrial cancer, history of hysterectomy, parity, OC use ever, baseline HRT use, SSRI use, exercise, family history of myocardial infarction, diabetes, BMI. ¶Angina model variables removed: marital status, education, employment status, sexual orientation, depression score, history of cervical, ovarian, or endometrial cancer, parity, OC use ever, baseline HRT use, SSRI use, exercise, smoking, BMI. ⁎⁎Congestive heart failure model variables removed: marital status, education, employment status, sexual orientation, depression score, history of hysterectomy, parity, OC use ever, baseline HRT use, SSRI use, exercise, family history of myocardial infarction. ††Carotid artery disease model variables removed: race/ethnicity, marital status, family income, education, employment status, sexual orientation, depression score, history of cervical, ovarian, or endometrial cancer, history of hysterectomy, parity, OC use ever, baseline HRT use, SSRI use, exercise, family history of myocardial infarction. |
Discussion The present study identified a higher prevalence of peripheral arterial disease among women who reported sexual dissatisfaction at baseline. However, no association between baseline sexual satisfaction and the other cardiovascular diseases investigated, including myocardial infarction, stroke, coronary revascularization, and congestive heart failure was found. Decreased sexual satisfaction at baseline did not predict incident cardiovascular disease. A number of factors may account for our overall null findings. Sexual satisfaction is a complex, multi-factorial construct. Psychosocial stressors, comorbid medical conditions, and nonvascular organic pathology play a large role. Although we designed our study to explore and control for other potential contributors to sexual satisfaction in these women, including medical, psychiatric, and social covariates, it is likely that residual confounding remained. Sexual satisfaction may have a different meaning for women than it has for men. The underlying mechanism for sexual functioning may differ between men and women, with cardiovascular risk factors playing a stronger role in sexual functioning among men and other variables of greater importance in female sexual functioning. Although data on sexual satisfaction in men are limited, previous studies have shown a strong association between sexual dysfunction and cardiovascular disease or cardiovascular risk factors in men, including ischemic heart disease, hypertension, diabetes mellitus, and smoking.2, 21, 22 Recently, erectile dysfunction has been implicated as a sentinel sign of cardiovascular disease in men.3 Few studies have examined this association in women. Previous work has shown that among type I diabetics, diabetes control measured by factors such as A1C and BMI was associated with sexual dysfunction in men, but not in women, whereas psychological variables were prominent for both sexes.23 Additionally, the utility of phophodiesterase inhibitors has been shown to differ between men and women. Although widely used to treat sexual dysfunction in men, sildenafil has shown mixed results when used for treatment of sexual dysfunction in women,5, 24 suggesting a more complex mechanism of sexual functioning in women. We found increased prevalence, but not incidence, of peripheral arterial disease among women reporting low sexual satisfaction, even after controlling for smoking. One possible explanation for this disparity is that different adjudication procedures were used for prevalent versus incident disease. Prevalent peripheral arterial disease was determined based on patient self-report, whereas incident disease was formally adjudicated by trained physicians using standardized criteria. If, at baseline, subjects tended to over-report peripheral arterial disease, this may partially explain these findings. Alternatively, there may be an association between peripheral arterial disease and decreased sexual satisfaction at baseline because peripheral arterial disease predicts decreased sexual satisfaction, rather than the reverse. Because we do not have follow-up data on sexual satisfaction, we are unable to explore this further. There are several strengths of this study. The WHI-OS is a large cohort study with good representation of women across the country and across racial and ethnic groups. Rigorous adjudication procedures were used to determine incident cardiovascular disease. Additionally, this is the first study, to our knowledge, to describe the association of sexual satisfaction with either prevalent or incident cardiovascular disease in women. An important limitation of this work is that the sexual satisfaction construct has not been formally validated. The survey question used to determine sexual satisfaction has strong face validity and has similar wording to questions on other validated instruments. However, we cannot fully appreciate the extent to which this question measures the construct of sexual satisfaction versus other constructs that may be highly related to sexual satisfaction, such as overall life satisfaction. Conclusions Sexual dysfunction is a prevalent condition in postmenopausal women, as is cardiovascular disease. Many of the same pathophysiological mechanisms known to be risk factors for cardiovascular disease have been proposed to be responsible for sexual dysfunction in postmenopausal women. However, in our population of sexually active postmenopausal women, dissatisfaction with sexual activity was not predictive of incident of cardiovascular disease. This may be due to physiological differences in sexual functioning between men and women. Further study may better elucidate whether cardiovascular disease is an important element of female sexual functioning. Acknowledgments The WHI program is funded by the National Heart, Lung and Blood Institute, US Department of Health and Human Services. The funding organization had representation on the steering committee, which governed the design and conduct of the study, the interpretation of the data, and the preparation and approval of manuscript. The National Heart, Lung, and Blood Institute Program Office reviewed the manuscript before publication. WHI Investigators by Clinical Center Program Office: (National Heart, Lung, and Blood Institute, Bethesda, Md) Elizabeth Nabel, Jacques Rossouw, Shari Ludlam, Linda Pottern, Joan McGowan, Leslie Ford, and Nancy Geller. Clinical Coordinating Center: (Fred Hutchinson Cancer Research Center, Seattle, Wash) Ross Prentice, Garnet Anderson, Andrea LaCroix, Charles L. Kooperberg, Ruth E. Patterson, Anne McTiernan; (Wake Forest University School of Medicine, Winston-Salem, NC) Sally Shumaker; (Medical Research Labs, Highland Heights, Ky) Evan Stein; (University of California at San Francisco, San Francisco, Calif) Steven Cummings. Clinical Centers: (Albert Einstein College of Medicine, Bronx, NY) Sylvia Wassertheil-Smoller; (Baylor College of Medicine, Houston, Tex) Aleksandar Rajkovic; (Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass) JoAnn Manson; (Brown University, Providence, RI) Annlouise R. Assaf; (Emory University, Atlanta, Ga) Lawrence Phillips; (Fred Hutchinson Cancer Research Center, Seattle, Wash) Shirley Beresford; (George Washington University Medical Center, Washington, DC) Judith Hsia; (Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, Calif) Rowan Chlebowski; (Kaiser Permanente Center for Health Research, Portland, Ore) Evelyn Whitlock; (Kaiser Permanente Division of Research, Oakland, Calif) Bette Caan; (Medical College of Wisconsin, Milwaukee, Wis) Jane Morley Kotchen; (MedStar Research Institute/Howard University, Washington, DC) Barbara V. Howard; (Northwestern University, Chicago/Evanston, Ill) Linda Van Horn; (Rush Medical Center, Chicago, Ill) Henry Black; (Stanford Prevention Research Center, Stanford, Calif) Marcia L. Stefanick; (State University of New York at Stony Brook, Stony Brook, NY) Dorothy Lane; (The Ohio State University, Columbus, Ohio) Rebecca Jackson; (University of Alabama at Birmingham, Birmingham, Ala) Cora E. Lewis; (University of Arizona, Tucson/Phoenix, Ariz) Tamsen Bassford; (University at Buffalo, Buffalo, NY) Jean Wactawski-Wende; (University of California at Davis, Sacramento, Calif) John Robbins; (University of California at Irvine, Calif) F. Allan Hubbell; (University of California at Los Angeles, Los Angeles, Calif) Howard Judd; (University of California at San Diego, LaJolla/Chula Vista, Calif) Robert D. Langer; (University of Cincinnati, Cincinnati, Ohio) Margery Gass; (University of Florida, Gainesville/Jacksonville, Fla) Marian Limacher; (University of Hawaii, Honolulu, Hawaii) David Curb; (University of Iowa, Iowa City/Davenport, Iowa) Robert Wallace; (University of Massachusetts/Fallon Clinic, Worcester, Mass) Judith Ockene; (University of Medicine and Dentistry of New Jersey, Newark, NJ) Norman Lasser; (University of Miami, Miami, Fla) Mary Jo O’Sullivan; (University of Minnesota, Minneapolis, Minn) Karen Margolis; (University of Nevada, Reno, Nev) Robert Brunner; (University of North Carolina, Chapel Hill, NC) Gerardo Heiss; (University of Pittsburgh, Pittsburgh, Pa) Lewis Kuller; (University of Tennessee, Memphis, Tenn) Karen C. Johnson; (University of Texas Health Science Center, San Antonio, Tex) Robert Brzyski; (University of Wisconsin, Madison, Wis) Gloria E. 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a VA Boston Healthcare System, Mass b Boston University, Mass c Wake Forest University School of Medicine, Winston-Salem, NC d University of Washington, Seattle e Brigham and Women’s Hospital, Boston, Mass f Emory University, Atlanta, Ga g Memorial Hospital of Rhode Island, Pawtucket h Wayne State University, Detroit, Mich i University of Hawaii, Manoa j University of Virginia, Charlottesville.  Requests for reprints should be addressed to Jennifer McCall-Hosenfeld, MD, MSc, Boston University Medical Center, Section of General Internal Medicine, 801 Massachusetts Avenue, Suite 200, Boston, MA 02118.
The Women’s Health Initiative program was funded by the National Heart, Lung and Blood Institute of the National Institutes of Health, U.S. Department of Health and Human Services. Dr. McCall-Hosenfeld was supported by a Department of Veterans Affairs Special Fellowship in the Health Issues of Women Veterans. PII: S0002-9343(07)01178-3 doi:10.1016/j.amjmed.2007.11.013 © 2008 Elsevier Inc. All rights reserved. | |
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