Sexuality and health problems

 | January 1, 2007

Sexuality and health problems

Long-term medical conditions compound the sexual issues that men and women already face during the natural aging process. Heart disease, diabetes, cancer, and arthritis are just some of the illnesses that can have a serious, lasting impact on your sexuality. Treatments can also alter sexual functioning. What's more, the emotional effects of an illness often weigh as heavily as the physical ones. One or both members of the couple may experience depression, which is a major contributor to sexual problems.

As you might expect, the AARP sexuality survey found that healthy individuals are more likely to engage in sexual activity. The survey found that 44% of people who characterized their health as excellent or very good had intercourse at least once a week. But as health status declined, so did sexual activity. About 33% of the people with good health and just 20% of those with fair or poor health had intercourse this frequently. And many of the respondents reported that better health for either themselves or their partner would improve their sex lives.

When you're first confronted with an illness, things may look bleak. But many people are able to resume a satisfying sex life after an initial adjustment phase. The first step to overcoming these challenges is to investigate the potential effects of the disease and treatment on your sex life. This section provides an overview of some common conditions and how they affect sexuality in later life. But it is also important to discuss these issues with a doctor.

Keep in mind, too, that there are many ways to maintain physical intimacy. Some couples find that they can have a satisfying relationship without intercourse. However, even in the absence of sexual contact, preserving other forms of affection — such as hand-holding and cuddling — is crucial for maintaining a healthy, positive relationship.

A wide variety of illnesses can cause or exacerbate sexual problems, but given the scope of this report, it isn't possible to include information about all of them. Here is a closer look at some of the most common culprits.

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Heart disease

Your heart is linked to your sexual organs, both physically and metaphorically. When you have chest pain or a heart attack, it's usually because fatty deposits have narrowed your arteries (a condition called atherosclerosis) and the heart tissue is not receiving enough blood. When atherosclerosis strikes the coronary arteries, it's a good bet that other vessels in your body have met the same fate — including those that serve your genitals. Because the penis needs a rapid influx of blood to achieve an erection, it's easy to see why vascular disease is the leading cause of erectile dysfunction. Atherosclerosis may also cause female arousal difficulties by preventing sufficient amounts of blood from reaching sex organs. Engorgement of the blood vessels of the vagina is needed for adequate lubrication and arousal.

After a heart attack, many people fear that the exertion of sex will bring on another attack. In reality, the cardiovascular demands of sex are relatively mild — about the equivalent of walking briskly up two flights of stairs. A study in the Journal of the American Medical Association concluded that chances are only one in a million that a man who had previously had a heart attack would have another during or immediately following sex. Those who engage in regular physical activity are at the lowest risk.

Although your doctor will give you specific instructions when you leave the hospital, most people should be ready to resume normal sexual activity within four weeks after a heart attack. If you're recovering from bypass surgery, you may have to wait six weeks before having sex, and you may need to avoid positions that could strain your incision.

Likewise, chronic stable angina should not be a barrier to sex if you're accustomed to doing other things that require the same level of exertion. Some cautions apply, though. You cannot use Viagra, Levitra, or Cialis if you're taking a medication that contains nitrates (such as nitroglycerine); the interaction of these drugs can cause life-threatening drops in blood pressure. People with unstable angina may need to abstain from sexual activity altogether. If you have this condition, consult your doctor before engaging in sex.

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High blood pressure

Hypertension (high blood pressure), another form of vascular disease, also contributes to sexual dysfunction. It changes circulatory patterns in the body and damages the inner lining of arteries (the endothelium), both of which may decrease blood flow to the penis and vagina. Moreover, many popular blood pressure medications can cause erectile difficulties. In fact, sexual problems are a main reason why people stop taking drugs that lower blood pressure. But doing so can be quite dangerous, given that high blood pressure is a leading cause of stroke and also plays a huge role in the physiologic changes that underlie heart attacks and heart failure.

Problems attributed to high blood pressure or drug therapy for it include impotence and ejaculation problems in men, painful or uncomfortable intercourse and difficulty having an orgasm in women, and lack of desire in both.

In theory, controlling high blood pressure should help preserve or even improve sexual function. In practice, it doesn't, at least not according to large studies. It's possible, though, that improvements in some people are offset by sexual side effects of drug therapy in others.

Sexual side effects have been ascribed to virtually all classes of drugs used to control blood pressure (see Table 3). In most studies, it has been almost impossible to tell if the problem stemmed from drug therapy or high blood pressure itself. A few studies have suggested that different drug classes have different effects on sexual function, and one class — angiotensin-receptor blockers — may even improve it.

If you think a blood pressure drug is putting a kink in your sex life, talk to your doctor. Many different drugs are used to treat blood pressure, and with your doctor's help you may find a better alternative.

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Diabetes

Unchecked, diabetes can be devastating to sexual function. About 35%–50% of men with diabetes experience erectile dysfunction. The disease contributes to erectile problems in at least two ways: It can impair the nerves that instruct the arteries of the penis to dilate, and it can restrict blood flow to the penis by damaging the blood vessels. People with diabetes often have high blood pressure and high levels of cholesterol and other fats in the blood — all of which may further damage blood vessels and impede blood flow.

Among people with diabetes, erectile dysfunction usually develops gradually over a period of months or years. At first, the erection may not be as rigid as it had been or the erection can't be sustained. Sometimes, erectile dysfunction is the first sign that a man has diabetes.

Carefully controlling blood sugar can help prevent the vascular and neurological complications that contribute to sexual problems. But even with proper treatment, men who have diabetes are three times as likely as other men to develop erectile dysfunction.

For women, the sexual effects of diabetes are more subtle, but they can be equally distressing. Diabetes can damage blood vessels and nerves, interfering with clitoral sensation and vaginal lubrication and causing difficulties with arousal and orgasm. The disease may also cause low libido. In addition, high blood sugar contributes to frequent yeast and bladder infections, which can make sex uncomfortable or impractical for long stretches during treatment.

Many men with diabetes can take pills for erectile dysfunction, although these drugs are less effective for diabetes-related erectile dysfunction than for other causes. Studies have found that while approximately 70% of men with erectile dysfunction from other causes responded well to Viagra, only 57% of diabetic men with erectile dysfunction reported improvement. Other treatments — including drugs delivered by injection or suppository, vacuum erection devices, and penile prostheses — appear to be more helpful for diabetic men.

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Arthritis

The pain, stiffness, and flexibility problems common with arthritis often interfere with physical intimacy, especially when the hips, knees, or spine are involved. However, even people with severe arthritis can enjoy an active sex life.

A flexible attitude often compensates quite well for having a less-than-flexible body. Try different positions to find the one that is most comfortable for intercourse. For example, people with arthritis in the hips, knees, or spine often find sex most comfortable when both parties lie on their sides. Also consider expanding your sexual repertoire to include other mutually gratifying sexual activities besides intercourse.

Rescheduling sexual activity may also help. For example, if pain and fatigue are worse in the morning, plan on a romantic afternoon instead.

Many people find that taking a painkiller — or a long, warm shower — an hour before sex lessens muscle and joint stiffness. You can also place pillows under your joints to relieve pain. Special angled wedges or cushions that are designed to make intercourse more comfortable are available and can be easily found on the Internet. Another option is to replace your regular bed with a waterbed.

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Cancer

The physical and psychological ramifications of cancer can deal a serious blow to sexual functioning. Cancer's effects are both direct and indirect. The disease itself can cause fatigue and pain, and the diagnosis may also engender fear, depression, guilt, stress, and poor self-image.

Cancer treatments often produce another set of problems. Nearly half of the women who undergo treatment for breast or gynecologic cancer have long-term sexual problems. For men, prostate cancer treatment causes erectile dysfunction about 85% of the time; however, these effects vary based upon the type of treatment the man chooses. His chances of returning to sexual functioning also depend heavily on his age, his health habits, and the priority he places on sexual activity. A closer look at the impact of common cancer treatments follows.

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Surgery

In women, surgery that involves the pelvic organs can damage nerves, diminishing sexual sensation during intercourse. If a woman's ovaries are removed before she has reached menopause, she is likely to experience sexual problems because of the sudden absence of estrogen as well as testosterone. Breast removal denies women the pleasure of being caressed in this area, and it can have a psychological effect as well. After a mastectomy, many women struggle with body image issues and feel less sexually attractive.

For men, surgery for prostate cancer can cut nerves or arteries that are necessary for an erection. Even "nerve-sparing" operations lead to erectile dysfunction at least 20%–50% of the time. Regardless of the type of surgery used, most men do not regain potency for 6–12 months.

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Radiation

Radiation treatment for prostate cancer can damage the nerves and vessels that serve the penis. It may also affect testosterone levels, leading to low libido and erection difficulties. Men who've had this therapy may have problems getting or keeping an erection. Women who have had radiation to the pelvic area can develop scar tissue in the lining of the vagina that can cause pain during intercourse. Side effects of radiation treatment — such as fatigue, nausea, vomiting, and diarrhea — are also deterrents to sexual activity.

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Chemotherapy

Many of the side effects of chemotherapy, such as nausea, hair loss, weight changes, and diarrhea, can squelch desire, damage a person's self-image, and prompt depression. Women may also notice vaginal dryness and pain. In addition, estrogen levels can drop radically during treatment, causing menopause-like symptoms. Erectile dysfunction is sometimes a side effect in men, but diminished testosterone levels and ejaculation problems are more common. Both sexes report lower sex drive and less frequent intercourse.

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Other treatments

Hormone therapy for prostate cancer is aimed at reducing testosterone levels. As a result, approximately 80% of men undergoing this therapy experience low desire, erectile problems, and lack of orgasm.

The sexual effects of tamoxifen, a drug used by women to prevent breast cancer or its recurrence, are not clear. Some studies have shown that it can cause vaginal dryness or tightness, especially in postmenopausal women.

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Depression

A complicated relationship exists between depression and sexuality. Depression can be both the cause and the result of sexual problems. For example, loss of desire can be a symptom of depression. Or it may appear first and provoke depression. A lack of interest in sex can lead to relationship problems, feelings of inadequacy, and other emotional issues, which in turn can result in depression. Libido isn't the only aspect of your sexuality affected by depression. Women may be less likely to have orgasms when they are depressed. And in one study, depressed men were twice as likely to experience erectile dysfunction as those who weren't depressed.

Two studies suggest that hormones may be one source of the connection between depression and sex. Data from the Harvard Study of Moods and Cycles, published in 2003, revealed that women with a history of depression were 20% more likely to enter perimenopause sooner than their nondepressed counterparts. For the most severely depressed women, early onset of perimenopause was twice as likely. Another study described a similar effect in men: The depressed men secreted lower levels of testosterone than those without depression.

Further complicating the issue are the sexual side effects of many frequently prescribed antidepressant drugs. Medications called selective serotonin reuptake inhibitors (SSRIs) — which include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) — can dampen desire and make it difficult to become aroused, sustain arousal, and achieve orgasm. Antidepressants can also cause vaginal dryness. An article in Psychiatric Annals suggests that as many as half of all people taking SSRIs experience some sexual problems.

But you don't need to sacrifice your sex life in order to treat depression. Some newer antidepressants — including bupropion (Wellbutrin) and mirtazapine (Remeron) — are less likely to cause sexual problems. There are reports that bupropion may boost sexual drive and arousal, as well as the intensity or duration of an orgasm. Older medications, known as tricyclic antidepressants and monoamine oxidase inhibitors, don't usually cause sexual problems, but they have other potentially dangerous side effects. Your doctor can help you sort out which medication is right for you.

If you're taking an SSRI, other approaches may help offset or eliminate sexual problems:

Lowering the dose. Sexual side effects may subside at a lower, although still therapeutic, dose.

Taking a drug holiday. Depending on how long the antidepressant medication usually remains in your body, you might stop taking it for a few days before a weekend, if that's when you hope to have sex. This is hardly spontaneous, but it can work if you carefully follow your doctor's directions about how to stop and resume your medication. However, there is always a chance that this might cause a relapse.

Adding a drug. In both men and women, Viagra may counteract the negative sexual effects of SSRIs. A study published in the Journal of the American Medical Association in 2003 found significant improvement in erectile function, arousal, ejaculation, orgasm, and overall satisfaction among men who took Viagra to counteract sexual problems stemming from SSRI use. Adding bupropion to your treatment may also offset the sexual side effects of SSRIs.

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Medications

There are hundreds of potentially lifesaving medications available today to treat heart disease, depression, and a host of other problems. The downside is that some of these drugs can impair your sexual enjoyment. Table 3 lists commonly used medications that have been shown to have sexual side effects in some people. A word of caution: If you think a drug you're taking is hampering your sexual functioning, don't stop taking it without talking to your doctor first. He or she may be able to adjust your dosage or switch you to a drug that you tolerate better.

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Review Date: 2007-01-01

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