Women’s Sexual Issues After Myocardial Infarction

Women’s Sexual Issues

After Myocardial
Infarction
A Literature Review
Amir Emami Zeydi, MSN, CCRN; Mohammad Sharafkhani, BSN;
Mohammad Reza Armat, MSN; Kathleen Ahern Gould, PhD, RN;
Aria Soleimani, MD; Seyed Javad Hosseini, MSN

Background: Sexual activity after myocardial infarction (MI) is a concern for

patients and often a challenge for health care professionals to address.
It is widely recognized that most patients, of both sexes, report sexual
problems or concerns after MI. However, there are reported differences
between men and women. Women with sexual concerns may seek
less help from health care providers and are more inclined to conceal
them because of cultural barriers.
Objective: The aim of the current study is to present a comprehensive
review of the literature describing women’s sexual issues after MI.
Method: A systematic search of the relevant literature was
performed within international databases, including PubMed/Medline,
Scopus, ScienceDirect, and ProQuest, as well as Google Scholar
using relevant keywords. Also, Persian electronic databases such as
Magiran, Scientific Information Databases, and Iran Medex were
searched from the inception to October 2014. Articles focusing on
the sexual issues after MI only in women, as well as articles on both
sexes where women’s results could be separated, were included
in this review.
Results: A total of 8 articles were included in the final dataset. The
main themes of women’s sexual concerns after MI were ‘‘loss or
decrease of sexual activity,’’ ‘‘dissatisfaction of sexual relationship,’’
‘‘doubt about resumption time of sexual activity,’’ ‘‘fear of
reinfarction or sudden death during sexual activity after MI,’’
‘‘knowledge deficit regarding sexual activity after MI,’’ and ‘‘poor
performance of health care providers in sexual counseling.’’

DOI: 10.1097/DCC.0000000000000187 July/August 2016 195

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 Women’s Sexual Issues After Myocardial Infarction

Discussion: The results of this review demonstrate that women’s post-MI

sexual activity is affected by many concerns. The concerns may be a
knowledge deficit related to not receiving necessary consultation on
this topic. Nurses, as first-line care givers, can provide appropriate
consultation and education for patients post-MI. As a result, breaking
taboo imposed by cultural barriers, personal assumptions, or lack of
confidence on giving sexual consultation may ultimately help patients
to improve their quality of life.
Keywords: Female, Myocardial infarction, Sexual behavior, Sexual
dysfunction, Sexual issue, Women
[DIMENS CRIT CARE NURS. 2016;35(4):195/203]

BACKGROUND are more inclined to conceal them because of cultural

Myocardial infarction (MI) is among the most prevalent
causes of death and disability globally for both men and
women. Worldwide, it is estimated that approximately
more than 7 million MIs occur annually.1 Patients surviv-
ing MI may cope with disease aftermaths and symptoms,
which require continued treatments and lifestyle changes.2
It has been shown that MI, as a dramatic example of a
major life crisis, can put a significant burden on affected
patients and their family by influencing physical, social,
and psychological aspects of life. These affect patients’ and
their family’s quality of life (QoL).3,4
Sexual activity after MI, as a major component of
QoL, is a concern for patients and often a challenging
topic for health care professionals to discuss.5 Problems
with sexual activity may have an unfavorable impact on
patients’ overall well-being and self-esteem.6,7 It has been
shown that there is an inverse relationship between sexual
satisfaction and psychosocial problems such as anxiety
in patients with MI. Therefore, appropriate consider-
ation of patients’ sexual concerns after MI may alleviate
this issue.8 Maintaining desirable post-MI sexual activity
(PMISA) may play a major part in patients’ long term re-
lationships and its resumption is considered extremely im-
portant to patients by them.9 Sexual issues often cause
great concern to patient because of a potential reduction
in the frequency of sexual interest, activity, satisfaction,
and performance.10 A study by Klein et al11 showed that
among patients who survived an MI after 4 years, two-
thirds claimed complete abstinence or diminished sexual
activity, whereas others reported full resumption. Although
it is widely recognized that most patients after MI in both
sexes experience sexual problems,10,12 women’s quantity
and quality of the sexual activity are reported to be less
than that of men.9,13 However, women with sexual con-
cerns may seek less help from health care providers and
barriers.9 There is a growing body of research demon-
strating that women were more likely than men to have
impairment in their QoL after MI.14,15 Despite the known
importance of the sexuality element of QoL and couple
relationships, particularly after MI, health care profes-
sionals frequently avoid or omit to evaluate sexual history
or offer counseling to patients about sexual issues, espe-
cially in acutely ill individuals.8,16 It has been stated that
most cardiologists and nurses do not routinely ask car-
diac patients about sexual issues, and patients are often
reluctant or uncomfortable to talk about sex.17 Thus, it is
essential that health care providers maintain extensive
knowledge about post-MI sexual issues.18
The importance of sexual activity as a major aspect
of QoL and its potential effect on patients’ life after MI,
especially in women, as well as current increasing atten-
tion to this issue, encouraged this review. Nurses are uniquely
positioned to ask patients about such concerns and help them,
and their partners, to develop strategies to enhance sexual
activities, which may include education, strength
and physical conditioning programs, as well as pharma-
cological and emotional support.
The aim of the current study is to present a compre-
hensive review of the literature describing women’s sexual
issues and concerns after MI to expand knowledge about
this subject and identify strategies for improving the quality
of care for these patients.
METHOD
A systematic search of the relevant literature was per-
formed within international databases, including PubMed/
Medline, Scopus, ScienceDirect, and ProQuest, as well as
Google Scholar using the following search terms or their
combinations: sexual activity, dysfunction, sexual behavior,

196 Dimensions of Critical Care Nursing Vol. 35 / No. 4

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 Women’s Sexual Issues After Myocardial Infarction

sexual problem, sexual function, sexual concern, sexual
health, sexual knowledge, myocardial infarction, heart at-
tack, coronary artery disease, female, and women. In these
databases, the search was limited to the English language.
Also, we searched the Persian electronic databases, includ-
ing Iranian Journal Database (Magiran), Scientific Infor-
mation Databases, and IranMedex (Iranian Biomedical
Journal Database) with the equivalent keywords in Farsi.
Without any time limit, all articles containing the selected
keywords in the title, abstract, and text, including both
quantitative qualitative approaches, from the inception to
October 2014 were evaluated.
Articles focusing on the sexual issue after MI only in
women, as well articles on both sexes where women’s re-
sults could be separated, were included in this review.
Review articles and letters to editor were excluded.
The electronic search was complemented by reading the
reference lists of included studies.
The search strategy generated 2799 titles and abstracts.
After initial screening and evaluation, 2687 articles were
rejected. Removing duplicates and using secondary screen-
ing resulted in 7 articles to be included. Also, a manual
search of article references added 1 paper. In total, 8 articles
were eligible for inclusion (Figure 1). It should be noted
that because of the large number of results generated by
Google Scholar, and considering that the search results in
Google Scholar are normally sorted by relevance, only the
first 500 hits according to the order frame were reviewed.
RESULTS
This review included 8 studies including 6 quantitative
and 2 qualitative ones. Most included articles had been
published between 2010 and 2014 and originated from
peer-reviewed journals. ‘‘Loss or decrease of sexual
activity,’’ ‘‘dissatisfaction of sexual relationship,’’ ‘‘doubt
about resumption time of sexual activity,’’ ‘‘fear of re-
infarction or sudden death during sexual activity after MI,’’
‘‘knowledge deficit regarding sexual activity after MI,’’ and
‘‘poor performance of health care providers in sexual

Method and Data

Author and Year Objective Collection Sample and Setting Key Findings
9
Oskay et al, 2014 Evaluation of the impact Cross-sectional study was A total of 45 women with MI Compared with the women without any
of myocardial infarction carried out. The Female who were admitted to the cardiac disease, women with MI
(MI) on female sexual Sexual Function Index (FSFI), coronary intensive care unit significantly had lower frequency of
function including lubrication, of Kocaeli University in intercourse and also mean FSFI total
arousal, desire, satisfaction, Turkey and also 50 score, which indicated a high
pain, and orgasm during volunteers (selected from prevalence of sexual dysfunction in
sexual intercourse, was used the relatives and/or friends women with MI. In addition, 88.4% of
to evaluate the sexual of patients) without any women with MI who resumed sex
function in women. cardiac disease were selected. were worried that they may have
Twelve weeks after discharge, another heart attack or die suddenly
all patients were invited to the during intercourse.
Cardiology Clinic in hospital
for health control and the
assessment of sexual activity.
SLderberg et al, 201318 Describe women’s Qualitative study using A total of 11 women, who The results showed that the overall
experiences of sexual phenomenological admitted to a primary concept ‘‘anxious resuming of sexual
health 6 months after a hermeneutic approach was coronary intervention after activity’’ interpreted in terms of the
first-time MI used. Data were collected their first-time MI at 2 following themes: partner, support,
through semistructured hospital heart centers in and the heart disease’s influence on
interviews. Denmark were selected sex life and relationships.
through purposeful
In women with MI, fear of having a new
sampling. MI influences their sexual life. Also
their nervousness and anxiety delayed
resuming sexual life, and anxiety was
closely related to the symptoms
experienced during sex.

(continues)

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 Women’s Sexual Issues After Myocardial Infarction
Author and Year
19
Abramsohn et al, 2013
Lindau et al, 201212
Nilsson et al, 201220
Lunelli et al, 2008,21
198 Dimensions of Critical Care Nursing
Method and Data
Objective Collection
Full understanding of sexual A qualitative study using a
recovery in women after content analysis approach
the MI was used. Data were
collected through
semistructured telephone
interviews.
Identifying patterns and A multisite,
loss of sexual activity observationalYstudy of
1 year after hospitalization sexual activity-related
for AMI outcomes was conducted.
The sexuality module
included a 5-item sexual
activity and communication
assessment administered by
telephone interviewers at
1 and 12 months after
enrollment.
Explore sexual knowledge This was a descriptive- A total of 65 persons (46 men
in persons who had MI analytical study was carried
out using the ‘‘Sex after
MI Knowledge Test’’
questionnaire.
Describe the patients’ A cross-sectional study was
knowledge regarding carried out using a
resumption of sexual researcher made
activity after an AMI questionnaire.
Vol. 35 / No. 4
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Sample and Setting
A total of 17 women
purposively selected from
the Translational Research
Investigating Underlying
Disparities in Acute
Myocardial Infarction
Patients’ Health Status
Registry (TRIUMPH) study
participants in the United
States were included.
Among 4340 patients who A total of 59% of women reported less
enrolled in the TRIUMPH
study, United States, 1879
patients (1274 men and 605
women) whose 12-month
sexuality data were
available were evaluated.
and 29 women) who had
own experiences of an MI
and living with a partner
were recruited from the
10 local meeting places in
different areas of Sweden
using convenience
sampling.
A total of 96 patients (male
and female) were enrolled,
of which 30% were female.
This study carried out in a
cardiac hospital in the state
of Rio Grande do Sul, Brazil.
Key Findings
Sexual problems and concerns were
prevalent, including patient and/or
partner fear of ‘‘causing another heart
attack.’’ Few women received
counseling about sexual concerns or
the safety of returning to sex. Most
women who discussed sex with a
physician initiated the discussion
themselves. Inquiry about strategies to
improve sexual outcomes elicited key
themes: need for privacy,
patient-centeredness, and information
about the timing and safe resumption
of sexual activity. In addition,
respondents felt that counseling
should be initiated by the treating
cardiologist, who ‘‘knows whether
your heart is safe,’’ and then reinforced
by the care team throughout the
rehabilitation period.
frequent sexual activity in the 12 months
after the acute MI (AMI) and 13% of
women reported no sexual activity in
the subsequent year. No received
discharge instruction was the only
significant predictor of loss of sexual
activity for women. Only one-third of
women received discharge instructions
about resuming sexual activity.
Women who did not receive instructions
were more likely to report loss of
their sexual activity.
Overall, 45% of the women scored
maximum in the test. The lowest
level of knowledge among
women was about the timing of
resumption of sexual activity
and the risk of symptoms during
sexual activity.
A total of 72% of women doubted about
the timing of resuming of sexual
activity, and 37% of women reported
a decrease in frequency of sexual
activity after MI. Only 1 in 29 women
(3.4%) received sexual guidance after
AMI from health care providers.
(continues)
 Women’s Sexual Issues After Myocardial Infarction

Method and Data

Author and Year Objective Collection
Eyada and Atwa, 200722 Assess sexual activity in A cross-sectional study was A total of 35 female patients
female patients with carried out. All patients
unstable angina or were interviewed for
non-ST-elevation MI assessment of sexual
(NSTEMI) and to study the activity 12 weeks after
impact of cardiovascular discharge. The Arizona
rehabilitation on Sexual Experience Scale was
resumption of sexual used for the assessment of
activity. the severity of sexual
dysfunction for patients
who resumed their sexual
activity.
Drory et al, 200013 Comparison of sexual A longitudinal follow-up of the A total of 462 men and
activity of women and medical outcome and
men after a first AMI psychosocial adjustment of
participants was done using
structured interviews.
Sample and Setting
Sexual activity was a highly important
admitted to the intensive
care unit of Riyadh National
Hospital, Saudi Arabia, for
management of unstable
angina or NSTEMI were
enrolled.
51 women who admitted
into 1 of 8 hospitals in Tel
Aviv with a first AMI were
interviewed once before
discharge and again
3-6 months after AMI.
Key Findings
factor in the lives of 34.3% of the
patients. The frequency of sexual
activity was diminished in all patients.
Most patients (76.5%) resumed their
sexual relations after 9-12 weeks of
their heart problem. In sexual
relations, 35.3% of patients were not
satisfied at all with their sexual
activity, 41.2% were mostly
dissatisfied, and 58.82% patients who
resumed sex were worried that they
may have another heart attack or die
suddenly during intercourse.
Women reported less sexual activity and
less satisfaction with sexual activity
than men did. There was a positive
relation between education with
frequency and satisfaction with sexual
activity. Resumption of sexual activity
was reported 3-6 months after a first
AMI by 72% of the women.

counseling’’ were the main women’s sexual issues after
MI reported in the literature.
DISCUSSION
The findings of the present study indicate that women’s
PMISA pattern (including desire and frequency) may be
changing, and efforts to discuss these concerns with provides
represent opportunity for education and consulting. The
main factor contributing to these changes can be attributed to
the fear and anxiety of reinfarction or even coital death.
Approximately, one-fourth of patients do not resume
their sexual activity after MI.23 In a study by Drory et al,13
it was shown that in women, as compared with men,
PMISA and its related satisfaction significantly decreased.
Also, it has been reported that lubrication, arousal, desire,
satisfaction, and orgasm during sexual intercourse are
significantly reduced in women after MI.9 It was shown
that 83% of women experience less sexual desire after
MI.22 However, Brännström et al24 pointed out that 63%
of women considered the PMISA as very important. How-
ever, the tools used for assessment of sexual dysfunction
have not been stated to be culturally adapted.22
As evidenced, main barriers to women in resuming
PMISA are fear and anxiety of reinfarction or even coital
death.9,22 However, it was shown that there was no sig-
nificant difference in mortality of sexually active and non-
sexually active individuals after MI.12 In the study by
López-Medina et al, patients with MI experienced new
sexual patterns resulting from a constant fear that sexual
activity could cause a new heart attack.25 Similarly, it
has been reported that 88.4% of women and even 57.8% of
their husbands were anxious about resuming PMISA.9
According to women’s experiences, the physiologic changes,
such as increased blood pressure and heart rate, during
sexual intercourse could contribute to their anxiety. In
addition, it has been suggested that most of the patients,
particularly women, feel exhausted after MI.18 Many as-
sociate this exhaustion to post-MI depression.26-28 Possibly,
depression could predispose changes in sexual activity,
which in turn may affect sexual desire and satisfaction. It has
been indicated that half of the women experiencing MI
have mild to severe depression.29 A significant relationship
between depression and reduced sexual performance in
women after MI has been reported.9 Similarly, Eyada and
Atwa22 suggested depression as a barrier to resuming sexual
activity in women. On the other hand, the American
Heart Association considers changes in sexual activity
as 1 of the main reasons for depression because of change
in couples’ intimate relationships.30 Also, it seems that the
fear and anxiety of reinfarction or coital death may in turn
affect the couple’s intimate relationships.18
Receiving consultation from the health care providers
is a substantial remedy in resuming PMISA.31,32 Nurses,
as first-line caregiver, have a perfect position to deal with

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 Women’s Sexual Issues After Myocardial Infarction
Figure 1. Literature search and retrieval flow diagram.
sexual concerns and being proactive in assessing patients’
medical and psychosocial problems and selecting the best
interventions.33 Also, they can provide appropriate sexual
consultation that has often been overlooked.34 However, it
was shown that patients and their sexual partner receive
insufficient relevant information and consultation.24 Lack
of such information may lead to a reduction in desire for
and frequency of PMISA.25 It is believed that proper infor-
mation and awareness can reduce fear and anxiety in cardiac
patients.31 In line with this, Lindau et al12 reported that the
most important reason for reduction of sexual activity, as
women believed, was receiving insufficient information and
consultation from health-care providers. Nurses may also be
reluctant to bring up the topic, despite its importance. Steink
et al34 showed that although 85% of the nurses were aware
of the significance of giving appropriate consultation on
sexual issues, only 21% provide it for their patients. At
the same time, 89% of women believe that health care
providers should discuss regarding PMISA.35
Reasons that may hinder receiving consultation for
PMISA include the gender of health care providers; pro-
vider age difference with female patients19; negligence/lack
of well-defined guideline to provide sexual consultation18;
insufficient time, knowledge, experience, and skill of health
care providers; and last but not least, religious and cultural
200 Dimensions of Critical Care Nursing Vol. 35 / No. 4
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
issues.10,24,36 As Lunelli et al21 stated, discussing sex mat-
ters is uncomfortable for some individuals. It may be ac-
companied by censorship, and at times, it is regarded as
taboo by both patients and nurses in many cultures.36,37
Admitting this taboo, Hoekstra et al38 state that in nurses’
belief, religious and cultural issues are among the major
barriers to patient education. Thus, the effects of reli-
gious and cultural differences should be acknowledged
in nursing programs.34
Drory et al13 found that there was a positive relation-
ship between received sexual education and sexual sa-
tisfaction. However, it has been reported that gender
is a prohibiting factor in giving sexual consultation to
women.35 Given the barriers for nurses to openly educate
patients about sexual activity, especially women, nurses
may engage more closely with patients and gain their
trust, offering a nonjudgmental attitude such as assur-
ing them that many patients have personal concerns and
that they may be able to offer guidance. Offering to listen
to personal and family concerns allows patients an oppor-
tunity to discuss these issues with nurses during hospitali-
zation, discharge, and recovery.19 Klein et al39 indicated
that the educational programs for sexual therapy includ-
ing patient education, cognitive restructuring, emotional
support, medical guidance, and imagery have significantly
 Women’s Sexual Issues After Myocardial Infarction
Figure 2. Possible influential factors of PMISA in women.
increased the frequency and quality of PMISA. The quality of
education is also important as some patients asserted that
the information they received was vague and confusing.19
Therefore, nurses should openly discuss the issues with
patients in an honest and respectful way. Nurses and other
providers may also suggest patient resources, such as the
American Heart Association Web site, where patients can
search valid and reputable information privately.40
Patients’ concerns may arise either from their fear of
likely and unexpected adverse incidents during sexual
activity, or their lack of knowledge about different issues
regarding resumption of sexual activity.34 This requires the
nurses to take into account both psychological and physical
aspects of sexual matters32 (Figure 2). Discussing with the
patients the fact that sexual activity is the cause of less than
1% of re-infarction cases may considerably reduce levels of
fear and anxiety.41-43
Other factors potentially affecting women’s PMISA
include age, physical and psychological health, sexual part-
ners’ health, previous sexual experiences, self-esteem, and
the value given to sex by the couples.44-46 To add to these,
specific classes and subclasses of medications, particularly
the first- and third-generation "-blockers, may contribute
to changes in sexual activity after cardiac events.33 Thus,
nurses are expected to discuss the potential side effects
of such medications and adopt strategies to support pa-
tients’ sexual function.34 These issues as well as the pa-
tients’ viewpoints regarding sexual activity have not been
deeply investigated. As most studies reporting on PMISA
are quantitative in design and examine issues limited to
resumption, frequency, and satisfaction, the American
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Heart Association emphasizes on deeper scrutiny to im-
prove PMISA.25,30
CONCLUSION
The results of this review demonstrate that women’s
PMISA concerns may affect overall recovery. These
changes include decreased desire in and frequency of
sexual activity, possibly because of increased fear and
anxiety regarding reinfarction or even coital death during
PMISA. The root of these problems seems to be a knowledge
deficit related to not receiving necessary consultation on
this topic. Nurses, direct care providers, and patient educa-
tors can provide appropriate consultation and education
for patients post-MI. As a result, breaking taboo on giv-
ing sexual consultation may ultimately help patients to im-
prove their QoL. Authors believe that the complex nature
of the sexual-related concepts in female patients with MI
demands more studies using qualitative approaches to bet-
ter understand the topic.
Continued research may include existing tools and
methods and expand current work to represent issues
of diversity and culture. Also, it is suggested that further
investigations have focus on evaluating the relationship
of depression and medication side effects with sexual dys-
function, using interdisciplinary approaches.
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ABOUT THE AUTHORS
Amir Emami Zeydi, MSN, CCRN, graduated with a bachelor of science
degree in nursing in 2008 and master of science degree in critical care
nursing in 2011 from Mazandaran University of Medical Sciences, Sari, Iran.
Currently, he is a PhD candidate in nursing at the Mashhad School of
Nursing and Midwifery, Mashhad University of Medical Sciences, Iran.
Mohammad Sharafkhani, BSN, graduated with a bachelor of science
degree in nursing in 2013 from Mashhad University of Medical Sciences,
Mashhad, Iran. Currently, he is a master of science student in
medical-surgical nursing at the Mashhad School of Nursing and Midwifery,
Mashhad University of Medical Sciences, and working as a clinical nurse
in the coronary care unit at Imam Zaman Hospital in Mashhad, Iran.
Mohammad Reza Armat, MSN, graduated from the Mashhad
University of Medical Sciences in 1991 with a bachelor of science degree
in nursing. He completed his master of science degree in nursing at
Tarbiat Modarres University in 1995. He is an instructor in North
Khorasan University of Medical Sciences, Bojnourd, Iran. Currently, he is a
PhD candidate in nursing at the Mashhad School of Nursing and
Midwifery, Mashhad University of Medical Sciences, Iran.
Kathleen Ahern Gould, PhD, RN, serves as adjunct faculty at the
William F. Connell School of Nursing at Boston College and serves as
the editor in chief of Dimensions of Critical Care Nursing.
Aria Soleimani, MD, received his medical degree from Tehran
University of Medical Sciences in 1993. He did his postgraduate
training (residency) in anesthesiology at the Babol University of
Medical Sciences in 2003 and cardiac anesthesia fellowship at Iran
University of Medical Sciences in 2005. He is currently dean of faculty
of medicine and served as an assistant professor of anesthesiology
and critical care medicine at Mazandaran University of Medical
Sciences, Sari, Iran.
Seyed Javad Hosseini, MSN, graduated with a bachelor of science
degree in nursing in 2012 and master of science degree in
medical-surgical nursing in 2015 from Mashhad University of Medical
Sciences, Mashhad, Iran. Currently, he is working as a clinical nurse in
the coronary care unit at Imam Zaman hospital in Mashhad, Iran.
The authors have disclosed that they have no significant relationship
with, or financial interest in, any commercial companies pertaining
to this article.
Address correspondence and reprint requests to: Mohammad
Sharafkhani, BSN, School of Nursing and Midwifery, Mashhad
University of Medical Sciences, Ebne-Sina Street, Mashhad, Razavi
Khorasan, Iran (sharafkhanim881@yahoo.com).

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DOI: 10.1097/01.DCC.0000484603.03069.fd

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