After a heart attack, women often worry about the safety of having sex again, and many wish their doctors would talk about the issue more.
This is the result of a study involving interviews with 17 women who'd survived a heart attack in the past two years. The researchers found that while most rekindled their sex lives within a month of the attack, many also remained fearful about how sex could affect their hearts.
What's more, few had discussed the issue with their doctors. And according to Journal of the American Heart Association, when they had, it was the women, not the doctors, who broached the topic.
"Unfortunately, that's not surprising," said Emily Abramsohn, a researcher at the University of Chicago who worked on the study, published online July 24.
The women, who averaged 60 years of age, were all part of a larger study following heart attack survivors' health. In that study, only 47% of men and 35% of women said their doctors had talked to them about resuming their sex lives.
Fears around the cardiac dangers of sex may be unfounded, experts say. Many studies have shown that for most heart attack survivors, sex is a low-risk activity. Less than 1% of all heart attacks are triggered during sex, according to the American Heart Association (AHA).
Still, doctors may be unsure about what specific advice to give, said Dr Suzanne Steinbaum, a cardiologist and director of women and heart disease at Lenox Hill Hospital in New York City.
There are guidelines on the topic, issued just last year from the AHA and the American College of Cardiology. These recommendations offer up some general parameters: Having sex is "reasonable", for instance, when heart patients can climb two flights of stairs without having chest pain or trouble breathing.
One woman in the new study said her doctor told her just that. The problem, she said, was, "I could hardly climb two flights of stairs before I had a heart attack."
"We need to be able to tell patients more than that," said Steinbaum, who is also the author of Dr Suzanne Steinbaum's Heart Book, which addresses women's heart health, including sexual activity.
Sex involves emotional and mental well-being, too, Steinbaum noted, and women may have concerns about it, even if they feel physically fit. Depression, for instance, is common after a heart attack, and that might affect a woman's sexual functioning.
"We need to address the emotional and psychosocial issues, too," Steinbaum said.
Abramsohn agreed that doctors may not know what to say on the subject, and noted that there are also practical obstacles.
In the immediate term, your doctor is concerned with saving your life, she explained. Then, when you're being discharged from the hospital, the doctor may be focused on your medications or cardiac rehab; any discussion of sexual well-being may get lost.
But it is important for doctors to at least broach the subject, both Abramsohn and Steinbaum said. "If the doctor brings it up," Abramsohn said, "at least the woman will know it's important to them as well, and that she can talk to her doctor about it."
The women in this study had suffered a heart attack an average of two years before the interviews. All but one said they'd started having sex again within six months of the heart attack, but "fear" was common, Abramsohn's team reports.
Some also said their partners were afraid of hurting them.
So what can women do? "Know that you're not alone in having fears surrounding sexual activity," Abramsohn said. "And if you are concerned, bring it up with your doctor."
If you do that but still "feel you're not being heard", Steinbaum said, you can ask for a referral to someone who works with heart patients a social worker, psychologist or cardiac rehab nurse, for example.
Cardiac rehab programmes, which may be prescribed in the couple of months after a heart attack, involve supervised exercise and counselling on issues like depression and anxiety. A program may not specifically address sexual activity, Steinbaum said, but it may help women feel better, physically and emotionally.
"When you exercise and see that you're getting stronger, you also gain confidence," Steinbaum said.
She added that there may also be specific underlying reasons for sexual dysfunction after a heart attack – not only depression, but medication side effects or abnormal thyroid hormone activity, for example. That's another reason it's important to talk about sexual issues with your doctor, Steinbaum pointed out.
"If you don't feel like you're getting back to normal after a heart attack," she said, "it's not your fault."
There's more on sex and heart disease at the American Heart Association.