VIDEO
Sex and the Heart
Relationships based on trust, understanding and love are not casual, and as they develop, no undue stress is placed on the heart. Above all else, if you are involved in a loving new relationship, do not let your anatomical heart interfere with your emotional and happy heart!
Questions you may find difficult to ask to your doctor
What happens to my heart when I am making love?
As you become aroused, your heart rate begins to increase and you breathe a little faster; as the excitement increases, both the heart rate and the blood pressure increase, reaching their peak at orgasm and settling back to resting levels after about three minutes’ rest. The average duration of sex is 15 minutes and the heart is really only stressed for 3 minutes.
If the heart rate is increasing, is sex stressful to the heart?
Sex is just another form of exercise as far as the heart is concerned. We have already said that angina pain can be brought on by exercise, so pain could occur during sex, but the important point is that sexual activity is no more stressful to the heart than other normal daily activities. In one study using tape recordings of the heart beats during sex, the heart rate averaged 120 beats per minute and was less than that often seen during other daily activities.
In another study, the blood pressure rise was not found to be dangerous or exaggerated.
The stress to the heart during sex is the same as 4 minutes on a treadmill exercise ECG. If you can do more than 4 minutes on that, making love should be OK. If your partner needs to be reassured, ask the doctor to arrange for the exercise ECG test to be performed in the presence of your partner.
Is casual sex more stressful to the heart than with a partner in a long-term relationship?
Yes, casual sex can be more stressful. Long-standing relation ships, where people are comfortable with each other, should present no problem, but a casual encounter can lead to a greater heart rate rise. This is not harmful to a normal heart, but if coronary disease is present, problems may occur. There may be an age mis-match (older man, younger woman) and the environment unfamiliar (a hotel room), following too much food and drink (casual sex at an office party). ‘Playing away’ can therefore be risky.
You sometimes hear horror stories of people dying while they are making love. Are these stories true?
You can die at any time and this includes during sex! The risk during sex is very low indeed and no higher than during other normal daily activities. However, it may be significant that, of those who die or have a heart attack during sex, 75% are having extra – marital sex, and 95% are men: so the advice is, beware!
I had a heart attack recently. How soon can I start making love again?
After a heart attack, providing there were no complications, sexual activity can be resumed in 2–3 weeks. Ask your doctor and use a stairs, walking or treadmill test as your guide. The advice is the same whether the patient is male or female. Sex is normal and not unduly stressful for couples with a longstanding relationship and should be enjoyed as much by those with heart disease as those without. As you recover from a heart attack and return to normal activities, you should be able to return to the normal activity of sex.
I am in my early fifties and have had a heart attack. Am I too old for sex?
Age is not a barrier and even those in their seventies or eighties, who were previously sexually active, should not be afraid of resuming normal relations.
Men may take longer getting an erection and women may worry they are less attractive and find vaginal lubrication a problem. Sex should not be rushed – we have road rage but we don’t need sex rage! Take your time, enjoy the build-up, and use lubricants if necessary. Age is a time for mature reflection, and a few wrinkles here and there do not detract from the beauty of the person within.
I had heart surgery 3 weeks ago. My husband is keen to make love again. Can I resume lovemaking safely?
You can resume as soon as you feel able. Chest wall pain can be a problem particularly when you are positioned underneath your husband. Mutual foreplay without full sex can be a satisfying alternative and may be a good way to restart sexual activity, particularly if your chest wall gives you some pain. Alternatively, try the side-to-side position, or experiment to find a position that is comfortable to both of you.
After angioplasty, you can resume sex within two to three days, depending on whether your groin is bruised or painful.
As a useful guide, the stress on the heart equates to walking briskly (in 10 seconds) up and down two flights of household stairs (13 steps each) or walking one mile on the flat in 20 minutes. If no pain or undue breathlessness occurs, then sex should be symptom free. If angina does occur during one of these tests, repeat it following sublingual nitrate tablets or spray. If nitrates are effective, they can be taken before sex. Indeed, as a side effect, there is some evidence that nitrates improve sexual pleasure. Nitrates should not be used if Viagra, Levitra or Cialis has been taken.
My partner has recently had heart surgery but has been given the all clear. Are some positions during lovemaking dangerous?
No, not within the bounds of common sense. The heart does not appear to be unduly stressed in any position as long as the relationship is long-standing. Casual sex can be more stressful to the heart.
The coarse hair which grows back on your partner’s chest, where it has been shaved, may be uncomfortable for you (‘it feels like a hedgehog’), and a small soft cushion placed between you can help (the sort of size you get on aeroplanes).
Since I came back from hospital following a heart attack, I’ve had no interest in making love. It upsets my partner and frustrates him. What should I say to him?
Most people resume sex as frequently as before the heart attack or surgery but others are less active. Some people are afraid that sex may damage the heart, spoiling a previously enjoyable sex life. They are often influenced by what is called ‘
Anxiety and depression may decrease your desire but, as your condition improves, your desire usually returns. Because you have a heart problem, you are now more aware of the heart beating, whereas before it had never concerned you. It will increase during lovemaking but there is nothing to fear: do the stair or walking test again to reassure yourself.
If you are depressed (which is not unusual) after your heart attack or surgery, it usually lifts quickly (90% of the time), but a small number of people will continue to feel depressed and this will reduce or remove any desire for sex. When you do make love (infrequently), it is not fulfilling. Do not accept this situation – you are not ‘past it’ – seek help from your doctor. Medication for depression – often for only a short time – is very effective and side effects are not usually a problem.
At first, it may be that just touching, holding and caressing without intercourse will help you slowly return to a full sex life.
I have been diagnosed with angina. Will heart disease affect my sex drive?
No. There are too many people who believe in myths like this. Some think that their sex life is all over when they get to 50. This should be the prime of life. In medical terms, you will be pleased to know that middle age extends to 70 years! Once your symptoms have been dealt with, you should be able to resume lovemaking.
My wife and I have always had a vigorous and adventurous love life. Now I am worried that I may get angina while I am making love. Is this likely?
Angina may occur and is best treated with sublingual nitrates beforehand. Keep nitrates by the bedside, and take an extra spray or tablet if angina occurs during sex. Rest for 5-10 minutes, then resume if you wish to. If prolonged pain occurs, it could be a heart attack (this is very unusual): if the pain persists after 30 minutes, seek medical help. If angina is of a severity to limit sexual activity on a regular basis, you should be considered for fuller investigation with a view to angioplasty or surgery.
Breathlessness during sex may respond to nitrates but, if heart failure is the problem, your partner will need to adopt a more active role, and different positions could be tried. If you don’t usually lie underneath, try this less stressful position or sit in a chair with your partner astride, facing you.
To be honest, our love life wasn’t up to much before the heart attack. Will it get worse?
If you were having sexual difficulties (such as lack of interest, poor satisfaction, or inability to sustain or develop an erection if you are male) before your heart problems, these will get worse. It is important to talk about these problems, either individually or together with the doctor or members of the rehabilitation team. Specific sexual counselling from trained counsellors may help.
I have heart failure and find that sex is too much effort. What can I do?
This is difficult because your heart’s pumping action has been reduced. The ACE inhibitors or AII antagonists improve the heart’s output and may help. Ask your doctor about them if you have not been prescribed them. Water pills (diuretics) may cause erectile dysfunction (impotence) as a side effect but you should not stop taking these.
It may be possible to reduce the dosage which can help. Unfortunately, if your breathing depends on taking diuretics, the dosage will not be reduced.
Heart failure patients may be unable to sustain a full sexual relationship but cuddling, caressing, close contact and even foreplay will still enable you to enjoy a satisfying relationship. Let your partner do most of the physical work and try different positions. If you are male and find that you can’t get an erection, ask about available treatments.
I am taking medication for my heart problem. Can medication affect my sex life?
The most obvious side effect of medication is male impotence – now known as erectile dysfunction or ED. Sometimes sex drive or desire (known as libido) can be reduced. Women may experience problems with arousal, desire, orgasm or feel pain due to lubrication problems.Drugs can be a problem, but it is most often the condition itself that leads to the ED in men. If a prescribed drug causes sexual problems it will do so in the first 2-4 weeks of its use and an alternative would then be worth trying. The drugs most often linked to ED are the betablockers and diuretics and in the female, sex drive or interest can be affected by beta-blockers. Statins used to lower cholesterol also very rarely cause sexual difficulties – mainly ED in the male. Whilst these effects may be drug-induced, they may also be psychological or due to your heart problem itself. Whatever you do, don’t stop your medication, as this may lead to more heart problems; equally, don’t accept the situation. Talk to your doctor: this is not a time to be shy or ‘British’. Ask your doctor whether the tablets might affect your sex life. The doctor will know what you are talking about. Changing medication or adjusting dosage may help. If you are feeling depressed, antidepressants may correct the problem. However, if ED or sexual dysfunction (such as poor female lubrication or lack of interest) continues, it should be evaluated further. You may be given hormones, and men may have their prostate checked. Get specialist advice.
Since being on blood pressure pills, my husband is having a problem getting an erection. Is there a connection?
Yes. Blood pressure tablets can sometimes cause erection failure in men and may affect some women also. If this happens, your husband should tell his doctor because a change in medication could solve the problem. Erectile dysfunction is more common with diuretics and beta-blockers and less likely with angiotensin II antagonists and doxazosin.
Everyone has heard about Viagra. My husband has a poor erection: will it help him?
Viagra is a truly wonderful drug, but it does not suit or help everyone with erection problems (known as erectile dysfunction or ED). In 8 out of 10 people it helps restore an erection in men. It is not an aphrodisiac, so the penis will still need normal stimulation to make Viagra work. Doses are 25, 50 and 100 mg, taken 1 hour before sexual foreplay, and its effects lasts for 4–6 hours. Heart patients may benefit from Viagra because heart disease, rather than the drugs used to treat it, is the most common cause of ED. Always get advice from your doctor and do not buy it on the Internet. It does not cause heart attacks (nor do other treatments), any more than might occur by chance. Before trying it, you should have a check-up at the doctor’s, and you may be asked to do an exercise ECG. Viagra reacts with nitrates and nicorandil. Oral nitrates and nicorandil must be stopped for 1 week before Viagra is used, and the nitrate tablets under the tongue or spray should not be used for 12 hours before or after Viagra. Nitrates plus Viagra can cause a dangerous fall in blood pressure. Otherwise, Viagra is a very safe and effective treatment, providing you are guided medically – do not experiment without a medical opinion.
A friend of mine had a heart attack after taking Viagra: it seems dangerous to me. What do media reports say?
There is no increased risk of a heart attack from Viagra – in fact there were fewer cases when Viagra was compared with a placebo (where there was no active tablet taken). Your friend probably took it without medical advice.
Does the effect of Viagra wear off the more you use it?
No. After a year, 87 out of 100 men who benefited from it, still did so.
What happens if I get angina during sex after taking Viagra?
Do not use a nitrate tablet or spray at the same time. Stop your activity and sit or stand up. The pain should gradually settle. A glass of whisky or brandy might be helpful. Do not try again until you have discussed the event with your doctor.
Are there other heart drugs that may react with Viagra?
Currently you are advised not to be on nicorandil (a potassium channel activator) or nevibolol (a beta-blocker) until research has reported that it is safe to do so.
Nitrates help my angina but I would like to try Viagra – what should I do?
Nitrates are relatively weak angina drugs, and have no proven benefit in preventing heart attacks or sudden death. They are used only to help relieve pain and breathlessness. Alternatives exist, so you can ask for your medicine to be changed. For example, you could try felodipine or amlodipine as alternatives. Once the change has proved successful (two weeks should be enough time), you can then try Viagra. Your doctor may need to ask a specialist about this, but most people can manage without nitrates.
I have tried Viagra but it only partly works – how can I improve things?
First of all don’t despair. Viagra does not always work first time you try it – indeed some people need seven or eight attempts before it ‘kicks in’. If it is not effective at 50 mg, try the 100 mg tablet. Only one tablet a day is advised and it should be taken on an empty stomach, and no smoking or alcohol is advised. It begins to work in 30 minutes, is at its peak after 1 hour, and gives you ‘a window of opportunity’ for 4-6 hours. Remember that you have to be stimulated for it to work. Side effects are not common. Headache and flushing with occasional indigestion occur but are not usually severe enough to warrant stopping taking it.
I have heard of newer Viagra-like drugs – are they any different?
There are two drugs that work the same way as Viagra – Levitra and Cialis. Their real names are sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis). They all work in the same way, by blocking an enzyme known as phosphodiesterase-5 (PDE5) which controls blood flow to the penis. Blocking PDE5 increases flow, so an erection occurs.
Levitra is very like Viagra and works at 5, 10, or 20 mg and, like Viagra, it is best to take it on an empty stomach to get the full effect by 1 hour. However, sex with a full stomach is not a good idea for heart patients. It is as effective as Viagra, so we can say it is an alternative which is worth trying.
Cialis is different in one way – it lasts longer. It is available as 10 or 20 mg equal to 50 or 100 mg of Viagra. It reaches its peak effect 1-2 hours after it is taken but may be active 36 hours later. It is not affected by food. Side effects are similar for all three drugs but muscle pains are more common with Cialis. ED success rates are similar. Cialis may, for some, allow more spontaneity but nitrates or nicorandil cannot be used for 48 hours afterwards. If you think you can’t have sex without the risk of angina, Viagra’s shorter action will be better for you, but when your condition has been stabilised and well controlled you will probably be given the choice.
Studies have confirmed the safety of all three drugs but they should only be obtained after advice from a healthcare professional and from reputable sources. Daily therapy with Cialis has now been approved at 2.5 and 5 mg doses which may allow more regular and spontaneous sex. You can use all three drugs if you want – for example, Cialis on Friday evening for a romantic weekend and Viagra as Levitra when a quicker action is needed. Many men like to try all three as there are slight differences and personal preferences are different; also, the hardness of the erection may vary.
If tablets don’t work do I have any other choices?
Indeed you do, so do not give up in despair. No treatment for ED harms the heart, so if one is safe, so are the others? Injection therapy and vacuum pumps are highly effective but need specialised advice, so ask for a referral. Before giving up on the Viagra approach, make sure you have tried the top dose. If you cannot take Viagra because you are on nitrates or nicorandil and they cannot be stopped, then there are other choices available.
Can I mix medications?
You can, but there is no safety information or clear research evidence of benefit. It is not recommended outside carefully controlled research studies.
All I hear about is men’s problems – do women get sexual difficulties and can they be helped, with Viagra for example?
Women certainly have sexual difficulties – known as female sexual dysfunction or FSD. Research is being done to see if treatments will help. The real problem is that the problem in men with getting an erection is obvious, whereas women’s problems are not.
Most doctors are men and have not been asking the right questions! Lubrication after the menopause is discussed above. Some drugs appear to suppress libido (sex drive or interest) and affect orgasms. Heart disease may also affect sexual confidence, as well as be a cause of reducing sexual enjoyment. Viagra may help, but we lack proof, so it is currently not recommended for women. Guidance is not really very clear, but still mention any problems that you are having – although we do not have clear-cut recommendations, by applying basic medicine and common sense, we may be able to help. Unless women raise the problem, the medical profession will not be aware of its scale and progress will be slow in helping.
Can you give me some advice in preparing for sex since my heart attack?
Improving exercise ability and losing weight will help sexual ability also. Here is some practical advice to minimise the stress on the heart during sex.
• Avoid sex within two hours of a bath or a heavy meal. Taking a shower and eating a light salad will be better.
• Keep the bedroom and sheets warm. You could invest in an electric blanket if it is cold.
• Don’t make love if you are tired at the end of the day. Wait until the morning when you are refreshed and relaxed.
• Avoid caffeine, smoking, or alcohol before or after sex. Alcohol may raise expectations that you cannot fulfil and it certainly does not enhance your sex life!
• If you get angina, use your nitrate tablets before lovemaking (but not if you are using Viagra, Levitra, or Cialis).
• Don’t rush into it – take your time.
• Use lubricants if necessary.
I have heard that K-Y jelly can be useful if lovemaking is a problem or painful. How safe is it to use?
K-Y jelly is a lubricant which can be particularly useful if your vagina is dry. This sometimes occurs after the menopause and can be a problem in patients with heart problems that naturally, but unnecessarily, feel reluctant or are afraid of resuming a normal sex life. K-Y jelly has no effect on the heart and is totally safe. It does not reduce the effectiveness of condoms or damage them. Topical oestrogens are also effective, and other non-hormonal moisturizers are available.
Where anal intercourse is practised, K-Y jelly is very helpful at reducing any physical trauma to the anus or penis, the pain of which occasionally causes palpitations.
Does oral or anal sex stress the heart?
Oral sex should not stress your heart, providing both you and your partner are comfortable with it. There is some evidence that anal sex increases palpitations but this has not been proved in a secure long-standing homosexual relationship.
I have resumed sex after my bypass and there are no problems, but I’m afraid that it might do some damage to the operation site. Is this possible?
Firstly, it is good to know that you have returned to a normal sexual relationship – we would like all people undergoing heart surgery such as yours to achieve the same, because it is safe and enjoyable. To answer your question directly – no, the operation cannot be damaged: stitches will not be torn and nothing will fall apart! It is important to remember that sex should be an enjoyable fulfilling experience whether there is heart disease or not – people with heart disease can enjoy a sexual relationship whatever their age.
I read in the newspaper that ED could be a marker for silent coronary disease. Is this true?
Yes. Over 50% of men with coronary disease have some degree of erectile dysfunction (ED) and it can occur 2–5 years before a coronary event. This is why men with ED and no heart complaints need checking for silent heart disease: their lives may depend on it.
My husband has lost all interest in sex even though he has made a good recovery from his small heart attack. Is it my fault?
Loss of interest in sex is known as loss of libido. It is not something you should blame yourself for. It could be a result of ED – a kind of vicious circle. A low testosterone level leads to lack of sex drive and sometimes ED. Your husband should be checked by his family doctor and get a blood test (before 10 a.m.) for testosterone. Men with low testosterones are more likely to get coronary disease but we don’t know if replacing or boosting it prevents coronary disease. If his testosterone is low, replacing it with a topical gel daily or an injection every 8-10 weeks can make the world of difference, restoring libido and overall energy and well-being. Tests for prostate cancer (prostate specific antigen, PSA) are done on the same blood sample because of a (very controversial) possible link between testosterone and prostate cancer- this is a precaution and should not put anyone off getting tested. As men get older, testosterone gradually falls but replacement or boosting works at all ages. No man or woman should consider themselves ‘too old’ for intimacy.
