Long term conditions, medication and sexual health

It is a rare drug that is not associated with at least some adverse effects, but many of the medications that are frequently used in the management of the most common conditions we see in primary care can have a profound effect on the most basic of human functions

It was Ian Dury and the Blockheads who suggested that sex and drugs and rock and roll might be ‘all my brain and body need’ but as health care professionals we may be inclined to disagree. More and more people are living with one or more long term conditions, and taking regular medication to treat ill-health or prevent complications so clinicians need to be aware of the potential impact on one of the most important of bodily functions, sexual health.

In this article we will be looking at the effect of physical and mental illness on sexual health and will consider the potential effects of drugs used to treat these conditions on libido and/or sexual function. Drugs that are most commonly associated with sexual dysfunction include those used in cardiovascular disease, and mental health problems (anti-psychotics and antidepressants).

By the end of this article you should be more familiar with:

• The need to consider the impact of physical and psychological ill health on sexual function
• How to address the issue with patients and their partners
• Which commonly prescribed drugs may affect sexual function
• What to do if patients are suffering from sexual dysfunction
• Resources available to people who are affected

CASE STUDY – MARK

Mark, age 54, had a myocardial infarction (MI) four months ago. The event had a profound effect on him, both physically and psychologically, as it came without warning and he’d always considered himself to be reasonably healthy. He’d been with clients at work when it happened and at first thought it was indigestion after a heavy, alcohol-laced business lunch earlier. However, the pain became intense quite rapidly and his colleagues quickly dialled 999 as he became pale, sweaty and nauseous. That action probably saved his life as he was found to have had an ST elevation MI and subsequently needed an angioplasty. It was a full 3 months before he felt mentally and physically able to return to work and there is no doubt that this put a strain on his finances and family life.

As a result of his heart attack Mark decided to clean up his act, stop smoking, lose weight and attend the cardiac rehabilitation (CR) course he was offered. He did well initially but found it hard to stay motivated and stopped attending the CR course after 4 weeks. He continues to attend the surgery for regular check-ups and monitoring, however.

Mark’s current medication includes ramipril 10mg, bisoprolol 5mg, atorvastatin 40mg, ezetimibe 10mg, aspirin 75mg, clopidogrel 75mg and a glycerine trinitrate spray that he rarely uses. He’s tried nicotine replacement therapy to quit smoking but didn’t get on with it so has switched to varenicline and is on his final 4 weeks of treatment. He has lost 2 stone since his cardiac event through watching his diet and walking more, and his BMI is now 35.8kg/m2. He has also cut down on his alcohol intake – it was previously 80 units a week but he has reduced it by half.

Mark attends with Diane for a cardiovascular review with the practice nurse at the surgery. The practice nurse has noticed that since his MI he has seemed much quieter than previously and today is no different. In the course of the consultation, Mark and Diane explain that their relationship has really suffered during the past few months since the MI and they are now considering a trial separation. Mark puts this down to problems in their sexual relationship and wonders ‘whether some Viagra might help, although it won’t help her!’

Diane does not seem to find this funny. She has been worried about Mark’s health for some time and the MI was proof to her that she had been right to worry and that he had been stupid to ignore her. She has type 2 diabetes and blames her poor control on comfort eating due to stress about Mark’s health problems. She currently takes metformin and gliclazide for her glycaemic control, as well as a statin and an ACE inhibitor. For the past two months she has also been taking a selective serotonin reuptake inhibitor (SSRI), fluoxetine, on her GP’s advice. She doesn’t drink or smoke but is obese with a BMI of 42.1kg/m2.

THE LINK BETWEEN SEXUAL WELLBEING AND GENERAL WELLBEING

There are several studies which demonstrate the importance of close physical contact, including sexual intercourse, in holistic good health.^1-3 Lindau and Gavrilova⁴ demonstrated that this effect continues throughout life, even in the elderly. An unsatisfactory sex life may therefore have profound implications for long term health and wellbeing. That is not to say that celibacy is a health risk per se, though, as other relationships such as those with friends and even pets can be very effective at helping people to stay happy and healthy.^5,6 However, there is no denying the impact that a mutually satisfying sexual relationship can have on the health of those involved.

The World Health Organization (WHO) has compiled a list of sexual health problems and states that although some may need specialist referral for treatment, all of them can be identified by primary health workers.⁷

ADDRESSING THE ISSUE OF SEXUAL DYSFUNCTION WITH PATIENTS AND THEIR PARTNERS

It is not always easy to broach this subject with patients and culturally, we tend to shy away from seeing sex as a key ingredient for health and one which should be a central part of lifestyle discussions. It requires courage and sensitivity from the clinician and the patient to be able to discuss these matters comfortably and confidently. It is often the case that practice makes perfect, however, and clinicians who are relaxed when talking about sexual issues are more likely to make their patients feel less embarrassed too. More information can be found at http://patient.info/doctor/sex-therapy-and-counselling

CONSIDERING THE CAUSES OF SEXUAL DYSFUNCTION

Looking at Mark and Diane’s story, it may be possible to spot some of the possible causes of their sexual problems. There is a direct link between many health conditions and sexual dysfunction, including diabetes, neurological conditions (including diabetic neuropathy), cardiovascular disease and mental health problems such as anxiety and depression.⁸ In the case of Mark and Diane, any and all of these may be relevant. Mark alluded to the fact that he is suffering from erectile dysfunction (ED) but that Diane may also be having problems with libido or anorgasmia too. In the past ED was considered to be mainly a psychological condition; nowadays, however, we recognise that physical problems often underlie the development of ED. In Mark’s case ED may be caused by vascular insufficiency, penile artery atheroma or low testosterone levels,⁹ but may also be related to stress, medication or lifestyle issues. Despite the fact that the most common type of sexual dysfunction is ED, clinicians should not overlook women’s sexual problems as a cause of disharmony in a relationship. Sexual problems that may affect women include those involved in libido (desire), physical arousal and orgasm. Lack of libido, inadequate response to stimulation (lack of lubrication or genital swelling) and inability to reach orgasm may be seen, and may be made worse by physical or psychological ill health. It is important not to assume the cause until a careful history has been taken with particular attention being paid to when the symptoms began. ED, for example, is known to be an important predictor of cardiovascular disease so may pre-date any event.¹⁰ Having a major event such as an MI or stroke can affect physical wellbeing but it may also have a profound effect on mental health too. Mark may be worried about over-exerting himself and Diane may also be worried that having sex may be dangerous. This fear of exertion – which they are both likely to have – cannot be overstated, as it is so common. These worries along with Diane’s depression may lead to reduced libido for both of them. Body image issues may also affect libido especially as they are both obese. As well as the conditions themselves, though, it is important to recognise that when it comes to the medication, the ‘cure’ may be part of the problem.

THE IMPACT OF PRESCRIBED MEDICATION ON SEXUAL FUNCTION

While the arguments for and against decriminalising cannabis use rage on and the discussion about the use of cannabis for medicinal purposes continues, health care professionals may be less aware of the potential issues around sex and drugs currently available through a standard FP10 form.

There are many types of prescribed drugs that may interfere with normal sexual function. However, there is also much debate about the overlap between the condition being treated and the drugs being prescribed when it comes to sexual dysfunction. When considering the medication Mark is currently taking, it is worth bearing in mind the following:

Beta blockers

There is a great deal of conflicting evidence about beta blockers and their impact on sexual function but selectivity for beta 1 and beta 2 receptors may be the key to choosing the right treatment to avoid impacting on sexual function. Bisoprolol is selective for beta 1 receptors and is less likely to cause ED than those which target B2 receptors. However, it has also been suggested that knowledge of the potential side effects of beta blockers may lead to anxiety which in itself may be the cause of the ED.¹¹

Statins

Sexual dysfunction has been reported with some statins but in controlled trials it was less easy to identify a cause and effect situation, with underlying vascular problems thought to be the key cause of ED in men.¹²

GTN spray

GTN is a vasodilator so should not interfere with erectile function or sexual function overall. However GTN should not be used with PDE-5 inhibitors such as sildenafil as this combination can lead to catastrophic hypotension and death.¹³

Varenicline

Sexual dysfunction is listed in the summary of product characteristics as a rare side effect although there seems to be no evidence to suggest a causal link.

ACE inhibitors

These drugs appear to be less likely to interfere with sexual function than other cardiovascular drugs.

In Diane’s case, her metformin and her gliclazide are unlikely to affect her sexual function, although arguably the risk of hypoglycaemia and weight gain associated with gliclazide might affect her psychological health. However, her SSRI may also be having an important effect on her, sexually speaking. Serotonin inhibits sexual function and as the SSRI increases circulating levels of serotonin, this may result in reduced libido and reduced ability to reach orgasm.¹⁴ All SSRIs have the potential to affect libido and sexual function although it goes without saying that untreated depression may have a significant effect on sexuality. A change of antidepressant could be considered. As previously mentioned, ACE inhibitors have no known impact on sexual function but interestingly, valsartan has been shown to improve it (in one study of post-menopausal women,¹⁵) so it may be worth considering swapping her ACE inhibitor for this angiotensin receptor blocker instead. A careful assessment of the risks and benefits of continuing, reducing or discontinuing medication will need to be carried out.

WHAT TO DO IF PATIENTS ARE AFFECTED

Mark was keen to know whether a PDE-5 inhibitor would help him with his erections. However, it would be important to consider the issues mentioned above and to exclude testosterone deficiency before prescribing (or referring on for) any treatment.⁹ His need for his GTN spray should also be borne in mind. Before stopping any medication, consideration should be paid towards the risk: benefit ratio of this action. These drugs are prescribed because the evidence base suggests that they will reduce the risk of further events in high risk individuals such as Mark and Diane. Lifestyle interventions could be optimised to potentially reduce the need for medication, thus minimising side effects. However, it may be that couples therapy may be indicated as well as consideration of current long term condition management. All decisions should be made with the patients and their informed consent or dissent regarding interventions should be respected.

RESOURCES AVAILABLE TO PEOPLE WHO ARE AFFECTED

As stated by the WHO, primary care clinicians may be well placed to identify sexual health problems as they are often known to the patients and may therefore be easier to approach. However, although some problems may be amenable to simple techniques such as sensate focus, a technique developed by Masters and Johnson (see http://counselling-matters.org.uk/sites/counselling-matters/files/SensateFocus.pdf) or the prescription of medication to help with ED, others may need a more specialised approach. In these cases, there may be a GP with special interest in the subject who could take a referral or, failing that, a referral can be made to the local sexual health services. Relate also offers help to people suffering from problems of sexual dysfunction. A downloadable book on ED is included in the resource section at the end of this article.

CONCLUSION

In summary, sexual health is an important part of holistic wellbeing for most people and primary care clinicians should take a proactive approach to screening for and assessing sexual dysfunction. Problems may be an indication of future cardiovascular risk or may be part of an existing condition, diagnosed or undiagnosed. Both men and women can suffer from loss of libido and problems achieving orgasm and men may also have problems getting and maintaining an erection. Sexual function may also be affected by medication being taken for a range of conditions. Careful history taking, assessment and investigation will be helpful in recognising the individual cause or causes of sexual problems and will then mean that the clinician can more easily identify the most appropriate intervention for couples like Mark and Diane, including knowing when to refer on.

REFERENCES

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2. Brody S. Blood pressure reactivity to stress is better for people who recently had penile-vaginal intercourse than for people who had other or no sexual activity Biological Psychology 2006;71:214-22.

3. Charnetski CJ, Brennan FX. Sexual frequency and salivary immunoglobulin A (IgA). Psychology Report 2004;94:839-44.

4. Lindau ST, Gavrilova N. Sex, health, and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of ageing BMJ 2010;340:c810

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7. WHO Sexual health issues, 2015 http://www.who.int/reproductivehealth/topics/sexual_health/issues/en/

8. Johannes CB et al. Incidence of erectile dysfunction in men 40 to 69 y old: longitudinal results from the Massachusetts male aging study. J Urol 2000;163: 460-463

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11. Grimm RH Jr et al. Long-term effects on sexual function of five antihypertensive drugs and nutritional hygienic treatment in hypertensive men and women. Treatment of Mild Hypertension Study (TOMHS). Hypertension 1997;29:8-14

12. Silvestri A et al. Report of erectile dysfunction after therapy with beta-blockers is related to patient knowledge of side effects and is reversed by placebo European Heart Journal 2003;24:1928-32

13. Solomon H et al. Erectile dysfunction and statin treatment in high cardiovascular risk patients Int J Clin Pract. 2006;60(2):141-145

14. Schwartz BG, Kloner RA (2010) Drug interactions with phosphodiesterase-5 inhibitors used for the treatment of erectile dysfunction or pulmonary hypertension. Circulation 2010;122(1):88-95

15. Werneke U, Northey S, Bhugra D. Antidepressants and sexual dysfunction. Acta Psychiatr Scand 2006;114:384-97

16. Fogari R et al. Effect of valsartan and atenolol on sexual behavior in hypertensive postmenopausal women. Am J Hypertens 2004;17:77-81