The American Journal of Medicine
Volume 121, Issue 4 , Pages 256-257, April 2008

Sexual Dysfunction and Coronary Artery Disease: What Applies to the Gander May Apply to the Goose

  • Richard D. Lane, MD, PhD

      Affiliations

    • Department of Psychiatry, University of Arizona, Tucson
    • ,
  • Julian F. Thayer, PhD

      Affiliations

    • Department of Psychology, The Ohio State University, Columbus, Mannheim Institute of Public Health, Social and Preventive Medicine, Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany

Article Outline

 

In this issue, McCall-Hosenfeld et al report that reduced sexual satisfaction in women is associated with prevalent peripheral vascular disease but not prevalent or incident coronary artery disease.1 Since a major study in 2005 demonstrated that erectile dysfunction in men is associated both with prevalent peripheral vascular disease and incident coronary artery disease,2 the findings by McCall-Hosenfeld and colleagues raise the possibility that in men, but not in women, sexual dysfunction is a “sentinel” sign of coronary artery disease that alerts the clinician to do a workup for coronary artery disease. The authors cautiously do not explicitly draw such a parallel, but readers of this journal may wonder whether the new findings in this issue warrant such a conclusion.

The possibility of a sex difference in this area occurs in the context of emerging evidence of sex differences across the entire clinical spectrum of ischemic heart disease, including risk factors, clinical presentation, treatment response and outcome.3 For example, in the context of acute myocardial infarction, women are significantly more likely than men to report multiple non-chest pain symptoms such as: dyspnea, nausea/vomiting, abdominal pain, back pain, neck pain, and jaw pain. Women, compared to men, also are more likely to have diffuse atherosclerosis, endothelial dysfunction, and microvascular disease.3 The findings by McCall-Hosenfeld et al, which are methodologically sound and noteworthy, appear at first glance to be consistent with this pattern of sex differences. We believe that it is important, therefore, to explicate our view of why it is premature to conclude that a sex difference exists in the degree to which sexual dysfunction is indicative of current or future coronary artery disease.

Although sexual dissatisfaction in women and erectile dysfunction in men are both associated with peripheral vascular disease, they are not physiologically equivalent. The physiological equivalent of erectile function/dysfunction in men is vaginal lubrication/dryness in women. The latter was not assessed in the paper by McCall-Hosenfeld et al, although it has been assessed in other studies.4, 5 Sexual satisfaction in women is determined by multiple factors, of which adequate vaginal lubrication is but one. The finding that sexual dissatisfaction correlates with prevalent peripheral vascular disease in women is consistent with the fact that the former is partially physiologically determined. However, the nature of the relationship that women have with their male partners is a critical determinant of their sexual satisfaction,6 whereas in men the frequency of sex tends to be a more important determinant of sexual satisfaction.7 Moreover, a proper medical evaluation of erectile dysfunction includes asking men whether they have erections in the morning, a phenomenon related to REM sleep and unrelated to the interpersonal context at the time.8 Thus, sexual satisfaction in women is a far more indirect index of intact sexual physiology than is erectile function in men. The failure to find that sexual satisfaction predicted incident coronary artery disease in women might well be because sexual dissatisfaction in women is a weaker index of physiologic function (ie, vaginal dryness) than is erectile dysfunction in men.

It is also important to consider that if an association between sexual dissatisfaction and incident coronary artery disease had been observed in women, it might have led to the potentially erroneous conclusion that equivalence did exist between men and women in the degree to which sexual dysfunction is a harbinger of future coronary artery disease. The reason is that new findings indicate that a relationship exists between positive emotions and better cardiovascular health. For example, higher levels of trait positive emotion (such as optimism) are associated with decreases in:

•The incidence of coronary artery disease9;

•Adverse cardiac outcomes (angina, recurrent myocardial infarction and cardiac mortality) in patients with established coronary artery disease10;

•Rehospitalization following coronary artery bypass graft surgery11;

•All-cause mortality in patients with coronary artery disease12; and

•Cardiac mortality in patients with coronary artery disease.13, 14

Consistent with these observations, Denollet et al15 observed that reduced state positive emotion was associated with elevated rates of recurrent myocardial infarction and cardiac mortality during the 2 years following implantation of coronary-artery stents. Given that sexual satisfaction in women is associated with greater life satisfaction overall,16 and that a more positive emotional outlook on life is associated with decreased incidence of coronary artery disease in both men and women,9 a finding that sexual dissatisfaction in women predicted incident coronary artery disease might have been due to the emotional component of the sexual satisfaction variable. This would contrast with the relationship in men between sexual satisfaction and a more proximal physiologic mechanism.

These considerations illustrate the importance of establishing equivalent physiological markers across the sexes to the extent possible. They also illustrate the need for investigators to be aware that emotions, both positive and negative,17 can have an important influence on outcome in coronary artery disease and that ignoring such factors can potentially lead to erroneous conclusions, particularly when interpretation of empirical findings is guided by the current medical zeitgeist.

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References 

  1. 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
  2. Thompson IM, Tangen CM, Goodman PJ, et al. Erectile dysfunction and subsequent cardiovascular disease. JAMA. 2005;294:2996–3002
  3. Tremmel JA, Yeung AC. Ischemic heart disease in women: an appropriate time to discriminate. Rev Cardiovasc Med. 2007;8:61–68
  4. Daker-White G. Reliable and valid self-report outcome measures in sexual dysfunction: A systematic review. Arch Sex Behav. 2002;31:197–209
  5. McGahuey CA, Gelenberg AJ, Laukes CA, et al. The Arizona Sexual Experience Scale (ASEX): Reliability and validity. J Sex Marital Ther. 2000;26:25–40
  6. Rosen RC, Barsky JL. Normal sexual response in women. Obstet Gynecol Clin North Am. 2006;33:515–526
  7. Beutel ME, Schumacher J, Weidner W, Brahler E. Sexual activity, sexual and partnership satisfaction in ageing men-results from a German representative community study. Andrologia. 2002;34:22–28
  8. Hirshkowitz M, Schmidt MH. Sleep-related erections: Clinical perspectives and neural mechanisms. Sleep Med Rev. 2005;9:311–329
  9. Kubzansky LD, Thurston RC. Emotional vitality and incident coronary heart disease: Benefits of healthy psychological functioning. Arch Gen Psychiatry. 2007;64:1393–1401
  10. Kubzansky LD, Sparrow D, Vokonas P, Kawachi I. Is the glass half empty or half full? (A prospective study of optimism and coronary heart disease in the normative aging study). Psychosom Med. 2001;63:910–916
  11. Scheier MF, Matthews KA, Owens JF, et al. Optimism and rehospitalization after coronary artery bypass graft surgery. Arch Intern Med. 1999;159:829–835
  12. Brummett BH, Boyle SH, Siegler IC, et al. Ratings of positive and depressive emotion as predictors of mortality in coronary patients. Int J Cardiol. 2005;100:213–216
  13. Giltay EJ, Kamphuis MH, Kalmijn S, et al. Dispositional optimism and the risk of cardiovascular death: the Zutphen Elderly Study. Arch Intern Med. 2006;166:431–436
  14. Giltay EJ, Geleijnse JM, Zitman FG, et al. Dispositional optimism and all-cause and cardiovascular mortality in a prospective cohort of elderly Dutch men and women. Arch Gen Psychiatry. 2004;61:1126–1135
  15. Denollet J, Pedersen SS, Daemen J, et al. Reduced positive affect (anhedonia) predicts major clinical events following implantation of coronary-artery stents. J Intern Med. (in press).
  16. Lau JT, Kim JH, Tsui HY. Prevalence of male and female sexual problems, perceptions related to sex and association with quality of life in a Chinese population: a population-based study. Int J Impot Res. 2005;17:494–505
  17. Strike PC, Steptoe A. Behavioral and emotional triggers of acute coronary syndromes: A systematic review and critique. Psychosom Med. 2005;67:179–186

PII: S0002-9343(08)00151-4

doi:10.1016/j.amjmed.2008.02.005

The American Journal of Medicine
Volume 121, Issue 4 , Pages 256-257, April 2008

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