Chronic medical illness and sex in aging

1. Chronic Medical Illnesses and
Sex in Aging
MARC EVANS M. ABAT, MD, FPCP, FPCGM
Head, Center for Healthy Aging, The Medical City
Consultant, Philippine General Hospital, Manila Doctors Hospital,
Cardinal Santos Medical Center

2. The Sexual Response Cycle

3. Cardiovascular disease
• Hypertension, Dyslipidemia and
Atherosclerosis
• Coronary artery disease
• Cardiomyopathy
• Valvular heart disease
• Cardiac dysrrhythmia
• Heart failure
• Peripheral arterial disease

4. Considerations
• Reduction in the cardiovascular endurance to perform
the sexual act
• Concerns about triggering an acute cardiac event
during the sexual act
– Angina and Acute myocardial infarction
– Arrhythmia
– Acute cardiac failure/congestion
• Circulatory problems leading to
– Poor erection
– Claudication/limb ischemia
• Anxiety and depression accompanying above concerns
effects on libido, erection, ability to orgasm

5. • Medication concerns
Medications Effects on Sexual Act
digoxin Decreased desire, erection, and frequency of sexual
relations
Beta blockers Small increased risk of fatigue and sexual dysfunction
Nitrates Preclude the use of PDE-5 inhibitors (e.g. sildenafil) to
improve erection
diuretics Loss of libido, difficulty initiating and sustaining
erection, and difficulty with orgasm
ACEi/ARBs Neutral to positive effects
CCB Poor erection, sexual dysfunction
Central agents
(clonidine,
methyldopa)
Poor erection. Loss of libido, impaired ejaculation

7. Recommendations for Care

8. General Considerations
• Sexual activity is reasonable in
– Low risk patients (Class IIa; Level of Evidence B)
– Can exercise >3 to 5 METS without angina,
excessive dyspnea, ischemic ST-segment changes,
cyanosis, hypotension, or arrhythmia (Class IIa;
Level of Evidence C)
• Cardiac rehabilitation and regular exercise
– useful to reduce the risk of cardiovascular
complications (Class IIa; Level of Evidence B).
Circulation. 2012;125:00-00.)

9. Coronary Artery Disease
• Sexual activity is reasonable for
– patients with no or mild angina (Class IIa; Level of
Evidence B).
– 1 or more weeks after uncomplicated MI if the patient
is without cardiac symptoms during mild to moderate
physical activity (Class IIa; Level of Evidence C)
– undergone complete coronary revascularization (Class
IIa; Level of Evidence B)
– undergone non-coronary open heart surgery (Class
IIa; Level of Evidence C).
Circulation. 2012;125:00-00.)

10. • For patients with incomplete coronary
revascularization
– exercise stress testing can be considered to assess
the extent and severity of residual ischemia (Class
IIb; Level of Evidence C).
Circulation. 2012;125:00-00.)

11. Heart Failure
• Sexual activity is reasonable for patients with
compensated and/or mild (NYHA class I or II)
heart failure (Class IIa; Level of Evidence B)
Circulation. 2012;125:00-00.)

12. Valvular Heart Disease
• Sexual activity is reasonable
– mild or moderate valvular heart disease and no or
mild symptoms (Class IIa; Level of Evidence C).
– Normally functioning prosthetic valves,
successfully repaired valves, and successful
transcatheter valve interventions (Class IIa; Level
of Evidence C).
Circulation. 2012;125:00-00.)

13. Arrhythmias, Pacemakers, and ICDs
• Sexual activity is reasonable for patients with
– atrial fibrillation or atrial flutter and well-controlled
ventricular rate (Class IIa; Level of Evidence C).
– history of atrioventricular nodal reentry tachycardia,
atrioventricular reentry tachycardia, or atrial tachycardia
with controlled arrhythmias (Class IIa; Level of Evidence C).
– pacemakers (Class IIa; Level of Evidence C).
– ICD implanted for primary prevention (Class IIa; Level of
Evidence C).
– ICD used for secondary prevention in whom moderate
physical activity (>3–5 METS) does not precipitate
ventricular tachycardia or fibrillation and who do not
receive frequent multiple appropriate shocks (Level of
Evidence C).
Circulation. 2012;125:00-00.)

14. Hypertrophic Cardiomyopathy
• Sexual activity is reasonable (Class IIa; Level of
Evidence C).
Circulation. 2012;125:00-00.)

15. Cardiovascular drugs that can improve
symptoms and survival
• should not be withheld because of concerns
about the potential impact on sexual function
(Class III: Harm; Level of Evidence C).
Circulation. 2012;125:00-00.)

16. PDE5 inhibitors (e.g. sildenafil, vardenafil,
tadalafil)
• useful for the treatment of ED in patients with
stable CVD (Class I; Level of Evidence A)
• Safety unknown in patient with severe aortic
stenosis or HCM (Class IIb; Level of Evidence C).
• should not be used in patients receiving nitrate
therapy (Class III; Level of Evidence B)
• Nitrates should not be administered (Class III;
Level of Evidence B)
– within 24 hours of sildenafil or vardenafil
administration
– or within 48 hours of tadalafil administration
Circulation. 2012;125:00-00.)

17. Other Concerns
• Nonsystemic (local or topical) estrogen use for
the treatment of dyspareunia in women with CVD
is reasonable (Class IIa; Level of Evidence C)
• caution patients with CVD regarding the potential
for adverse events with the use of herbal
medications with unknown ingredients that are
taken for treatment of sexual dysfunction (Class
IIb; Level of Evidence C)
Circulation. 2012;125:00-00.)

18. General Management
• Accurate risk stratification and Optimal
management of cardiovascular conditions
– Sexual dysfunction may have to be a tolerated
medication side effect in certain situations
• Use of comfortable sexual positions
• Use of non-penetrative sexual
activities/prolonging foreplay (e.g.
fellatio/cunnilingus/masturbation)
• Use of non-sexual activities to enhance physical
closeness, affection
• Judicious use of the PDE5 inhibitors

19. Respiratory Diseases
• Chronic obstructive
pulmonary disease
• Chronic respiratory
failure from other causes
(e.g. bronchiectasis, or
pulmonary fibrosis)
• Bronchial asthma
• Lung cancer

20. Concerns
• Shortness of breath and hypoxemia during
increased physical activity
– Leading to difficulty sustaining sexual activity
• Fatigue affecting desire
• Resulting asthenia contributing to difficulty in
participation and performance
• Unexpected pulmonary symptoms during
intercourse (e.g. excessive phlegm production,
sudden hemoptysis)

21. • Resulting anxiety and depressioneffects on
libido, erection, ability to orgasm
• Medication concerns (although generally less
due to localized pulmonary effects)
– Anticholinergic agents (e.g. ipratropium,
tiotropium)—decreased libido, vaginal dryness,
difficulty reaching orgasm
– Beta agonists (e.g. salbutamol)

22. Case Report
• 63-yr-old man, affected by severe (stage GOLD IV)
stable COPD, treated with long-term oxygen therapy
for 2 years
• evaluation performed 3x under stable conditions with
the patient breathing room air; no change in his
medications
• Most comfortable position used (standing or woman
on top)
• Oxygen saturation measured at
– 5 min before sex
– Duration of sex (from excitement to ejaculation)
– Up to 10 mins after sex
– More than 10-min after sex
Respiratory Medicine. June 2008. 102(6 ),927-931.

23. • Baseline evaluation using 6-
minute-walk
– Sudden and deep fall in
oxygen saturation during the
test
• Evaluation during sex (3
separate occasions)
– Increased in dyspnea
sensation
– Higher baseline heart rate
– Increase in heart rate during
sex
– Slower but steady increase in
oxygen saturation during and
within 10 minutes after sex
Respiratory Medicine. June 2008. 102(6 ),927-931.

24. • Attributed to increased ventilation and
perfusion relative to amount of muscles used
during sex

25. General Management
• Optimal management of respiratory condition
• Respiratory premedication prior to sexual activity
• Pulmonary toilette prior to sexual act
• Use of comfortable sexual positions
• Use of non-penetrative sexual
activities/prolonging foreplay (e.g.
fellatio/cunnilingus/masturbation)
• Use of non-sexual activities to enhance physical
closeness, affection
• Use of lubricants

26. Chronic Liver Disease
• Changes in circulating sex hormones
• Fatigue
• Medication effects (e.g. diuretics, beta
blockers)
• Water retention
• Autonomic dysfunction

27. Chronic Kidney Disease
• Co-morbidities related to vascular and
neuropathic complications of underlying cause
(e.g. diabetes mellitus)
• Effects of uremia
– Fatigue
– Decreased energy/endurance
– Uremic appearance and smell

28. Endocrine disorders
• Diabetes mellitus
– Microvascular complications (particularly
neuropathy)
– Macrovascular complications (e.g. heart disease,
stroke, kidney disease)
• Thyroid disorders
– Both hypo- and hyperthyroidism lead to decreases
in sexual desire, arousal, lubrication and orgasm

29. • Use of hormonal treatments or medication
effects
– Antiandrogens (e.g. bicalutamide)
– GnRH analogs (e.g. leuprolide)
– Increased prolactin (e.g. from use of
antidepressants)

30. Musculoskeletal Disorders
• Osteoarthritis
• Gout
• Rheumatoid Arthritis
• Disc disease
• Osteoporosis
• Spondylisthesis
• Radiculopathies

31. • Musculoskeletal pain or joint ROM limitation
may affect activities related to sexual
performance
• Neurogenic effects of structural disorders
• Vascular effects of long-term NSAID/COX-2
inhibitor use

32. This is a LAMP…….not a woman in
lithotomy position

33. The most powerful sex
organ is…..
THE BRAIN

34. Dementing disorders
• Impaired partner
recognition and relation
• Increased interest
hypersexuality
• Decreased or loss of
interest
• Decreased ability to
perform
• Aberrant sexual behavior
• Disinhibition
• Sexual abuse
• Alzheimer’s disease
• Vascular dementia
• Lewy Body dementia
• Frontal lobe dementia

35. • Medication effects
– Cholinesterase inhibitors (e.g. donepezil,
rivastigmine)increased libido
– NMDA receptor antagonist (e.g.
memantine)decreased libido
– Antipsychotics
• Better sexual performance (with relief of psychosis)
• Case reports of retrograde ejaculation, priapism with
risperidone and olanzapine

36. Cerebrovascular disease
• Motor and sensory
deficits
• Autonomic dysfunction
• Concerns about further
stroke episodes and
other neurologic
symptoms (e.g.
seizures)
• Psychologic issues
• Decreased libido
• Problems with arousal
– Erectile dysfunction
– Problems with vaginal
tone and lubrication
– Orgasm problems
• General difficulties with
participation due to
residual deficits

37. Parkinsonism
• Postural instability
• Rigidity
• Bradykinesia
• Autonomic
dysfunction
• Difficulties in
positioning and
performance
• Erection problems
• Orgasm difficulties
• Vaginal dryness
• Hypersexuality (side
effect of dopamine
agonists)

38. General Management
• Optimal management of the underlying condition
– Some medication effects may have to be tolerated
• Medication rationalization
• Appropriate timing of activities
• Use of comfortable sexual positions
• Use of non-penetrative sexual activities/prolonging
foreplay (e.g. fellatio/cunnilingus/masturbation)
• Use of non-sexual activities to enhance physical
closeness, affection
• Treatment