The question patients won't ask but want answered

Research indicates sexual problems and concerns are common after hospital discharge.

“Let's talk about sex” is a phrase hospitalists use less frequently than rappers Salt-N-Pepa might like.

It's also used less often than their patients would like, according to a recent study of women who had a myocardial infarction (MI) and were in a long-term relationship. The telephone survey of 17 women from the TRIUMPH Registry found that sexual problems and concerns, including fear of causing another heart attack, were common after hospital discharge and that counseling about sexual activity by physicians was rare. The study, which was published online by the Journal of the American Heart Association on July 24, concluded that by paying more attention to patients' sexual function, physicians could potentially improve health and functional outcomes after MI.

Courtesy of Stacy Lindau
Courtesy of Stacy Lindau.

Many hospitalized patients, not just those with cardiac problems, could benefit from a little more conversation with their physicians about sex, according to study co-author Stacy Lindau, MD. Dr. Lindau, associate professor of obstetrics/ gynecology and medicine-geriatrics at the University of Chicago, recently spoke with ACP Hospitalist about this common care gap and how hospitalists could fill it.

Q: How does hospitalization affect patients' sexual function?

A: A person who is sick is likely to see a decrease in her sexual interest, report less sexual activity, and be more likely to report sexual problems. Sexual problems in people with illness requiring hospitalization can be both biological and psychological in origin. The kinds of conditions that people get hospitalized for these days, aside from acute traumatic injury or acute infection, are typically complex conditions, many of which share an inflammatory root cause. Inflammation can have both peripheral and central effects on sexual function. Peripherally, we think of small vessel disease and neuropathy, both of which can interfere with sexual arousal and orgasm. Centrally, inflammation can reduce sex drive. There's evidence from animal models showing that some inflammatory proteins cross the blood-brain barrier and diminish an animal's sexual seeking behavior. It's very plausible that inflammatory conditions in humans have a similar effect.

Many patients who are hospitalized with an MI, or even cancer, felt that they were in pretty good health leading up to their diagnosis. Hospitalization is a time when patients are coming to grips with their diagnosis and how they want their life to be when they get home. Hospitalization for these kinds of conditions can be a very teachable moment. When it comes to sex, many people will report looking back that they had some decline in sexual function or activity in the months before hospitalization. Even still, we've heard many patients say, “I wish I appreciated my sex life more before this happened.”

When we think about transitioning a patient from hospital to home, there are a number of issues that we hope we're counseling them about. In the case of an acute MI, we're counseling patients about when they can resume their normal physical activities. To me, resuming sexual activity is just another dimension of physical activity that's important to people and that they will not ask about if the doctor doesn't bring it up. People are more prone to ask, “Hey doc, when can I go back to work?” They might ask, “When I can start golfing again?” They won't ask about sex, but they really want to know.

Q: How should a physician bring up sex during this conversation?

A: Hospitalists are busy with saving lives and safely getting people home. They can say something very simple, like “You can resume your normal physical activities at this time, including sexual activity.” It's not the right time and place for the doctor or the patient to go into an in-depth counseling session about relationship qualities or treatments for sexual dysfunction, but it is a really teachable moment, and it's a gift from doctor to patient to include that item of counseling even in the briefest way because it opens the door for future conversations.

“You can resume work, you can resume your physical activities, and you should be OK to resume sexual activity. If you have problems returning to any of those activities, please let me know and we can go from there.” A general statement signals that you care about [the patient] as a whole person: I'm not just a heart attack or a cancer, I'm a person who hopes to get back to a normal or even a better life than I had before. If I encounter problems or worries in any of these domains, I am not alone, and my doctor is there for me.

Q: For hospitalists, who might not be in the best position to follow up on this issue after discharge, are there places to refer patients?

A: The hospital discharge process should connect a patient to an ongoing source of care. The primary care provider is the place for a patient to start. There are some resources that hospitalists and primary care providers can use to identify colleagues who can help with patients' sexual concerns. For women, the International Society for the Study of Women's Sexual Health's website lists fellows of that organization, so doctors and patients can see who has interest and expertise in this area. There's another organization called American Association of Sexuality Educators, Counselors and Therapists, which certifies sex therapists, typically mental health professionals, and lists providers by geography on their website. The Society for Sex Therapy and Research also lists people who are experts in this field. Those people can help be front-line responders for people who have sexual concerns, both male and female patients. I feel strongly that patients with new-onset sexual function concerns should have a physical examination as part of their evaluation, even if just to reassure the patient of normal findings.

One more plug: I'm the founding chair of a new organization called the Scientific Network on Female Sexual Health and Cancer. We are a multidisciplinary organization of clinician-scientists across the U.S., Canada, United Kingdom and Australia who specifically care for women who have cancer and sexual concerns.

Q: Are there also resources to help physicians figure out what recommendations to make regarding sexual activity?

A: We continue to conduct research in this area. We're trying to understand what recommendations doctors are giving patients, especially after an acute MI. Are they recommending resumption of activity with no restrictions? Are they recommending restrictions? Who gets restrictions, who doesn't? We don't have enough information to know all the factors influencing what the doctor's going to say. It does appear that doctors are less likely to discuss these issues with women.

In the case of recommendations after MI, there are recently updated guidelines from both the American Heart Association and European societies around this. I'm not a cardiologist, but the general rule of thumb is if a patient can tolerate moderate exercise, or a few flights of stairs without chest pain or shortness of breath, they ought to be able to tolerate sexual activity. [This] question is begging for better evidence by disease, so that doctors feel comfortable making safe recommendations to patients. There's no good evidence that permitting patients to resume sexual activity when they feel comfortable to do so is harmful, especially with a long-term partner. Patients are pretty good at knowing [what they can handle].

Q: Why hasn't this topic become standard in physician-patient communication?

A: There have been many studies published in the peer review literature showing that there are barriers on both the doctor and the patient side to talking about sexuality—embarrassment is one of them, time is another. [Also, the] can of worms: “Whoa, this is a really big topic and if I open this can of worms, we're not going to have time or I'm not going to have the knowledge to address it.”

Q: What's your response to physicians who have these concerns?

A: In all of our studies, and in my clinical experience taking care of middle-aged and older women, overwhelmingly patients tell us that when their doctor raises the issue of sexuality, they feel that the doctor regards them as a whole person. I have not had a person say to me—and it doesn't mean those people aren't out there—”I was embarrassed by my doctor, I was ashamed, I thought my doctor was a bad doctor because he or she raised this issue.” For the people who aren't concerned, it goes right past them. For the people who care about this domain of their life, they're impressed that the doctor respects them enough to put it on the list of things they address.

People, even people in their 70s, 80s, 90s, tell us that they regard their sexual function as a component of their health. Even people who aren't sexually active say they see sex as an appropriate topic for discussion between doctor and patient. They're not saying they want the doctor to provide an hour-long counseling session. They just want the doctor to put it on the list of things that the patient might think about, and that way they know if they have a problem, it's appropriate to bring it to the doctor.