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