Online edition of Sunday Observer

Healthy sexual relationships hold the key to a happy marriage. Lack of basic knowledge and myths about sex on the other hand, can be a major set-back to a satisfying marital relationship. Today two doctors discuss some of these issues to allay some common fears about sex.

Myths and misinformation about sex and heart disease abounds among Sri Lankan heart patients. These myths do nothing but create needless fears which slow the patient's recovery. Although some Sri Lankan physicians and surgeons find sexual matters difficult to discuss with their patients, this area is a major concern for most heart patients. physicians should try to overcome their reticence and offer information in an objective and non-threatening fashion that will allay fears and anxiety. Resumption of sexual activity may be very important during the stressful readjustment period after a heart attack and after by-pass surgery.

Most patients are capable of physical exertion required (5 METS at orgasm) which is about the equivalent of climbing a flight of stairs briskly. On the other hand, angina during the intercourse is a possibility and can be devastating to a heart patient. Therefore it may be advisable for some patients to use a nitroglycerin (GTN) tablet 15-20 minutes prior to sexual activity, particularly before the first attempt after discharge from the hospital.

It is generally safe for an uncomplicated heart attack or by-pass surgery patient to have sex with his or her partner four to six weeks after leaving hospital. It is dangerous for heart attack and by-pass patients to have extra-marital sex as large quantities of catcholamines secreted by the adrenals can cause dangerous arrhythmias (palpitations) which can rarely cause ventricular fibrillation (cardiac arrest). It is the duty of the cardiologists who are doing cardiac rehabilitation, to discuss about their marital problems as part of cardiac rehabilitation.

A common myth among heart patients is that desire and intensity for sexual activity is the same in men and women as they age. This is not correct. In men there is a decline at a slow but steady rate after the age of 60 when it remains the same indefinitely. In females sexual drive peaks about the age of 27 to 30 and remains steady until menopause when it drops slightly. After menopause a woman is capable of sexual pleasure, in some cases even greater pleasure because of the lack of concern about unwanted pregnancy.

Another myth among heart patients is that sex after a heart attack is a frequent cause of death. In reality, this rarely happens and if so usually in an extramarital situation. As mentioned earlier, extramarital sex is more stressful than sex with the spouse for various reasons. The associated effects of too much of food and alcohol intake add to the overall stress and also extra-marital sex takes place in unfamiliar surroundings.

There is another myth among some Sri Lankans that alcohol is a powerful stimulant for sex. In some cases small amounts of alcohol may help to reduce tension, fears and guilt which may result in increased sexual performance and pleasure. But alcohol is a powerful depressant and may inhibit sexual function even more that it impairs speech, muscle co-ordination and judgement.

The long-term effects of alcohol are so damaging that an alcoholic who becomes importent may not recovery potency even after he stops drinking in spite of using modern drugs which are believed to stimulate sexual function which are dangerous for heart attack patients.

Another common myth is that decline in sex drive and function after a heart attack is due to the heart's inability to respond to the physical demand of sex. In reality except for a few people with severe heart disease and heart failure, the major impact on sex drive and function after a heart attack is psychological rather than physical. The demands of sexual intercourse are mild and are comparable to climbing a flight of stairs briskly.

Some heart attack patients believe that when angina occurs during sex, it is a warning sign to the patient to completely abstain from sex thereafter.

But the truth is that angina during sex is rarely severe enough to cause the patient to stop facing sexual relations. If the patient develops chest pain during sexual intercourse, his family physician will recommend a tablet of nitroglycerin (GTN) under the tongue 15-20 minutes before sexual activity to improve the heart function and to prevent development of chest pain.

When a couple feels comfortable and secure enough about their sex life, things begin to improve in other areas of their lives as well. Heart disease may alter a persons, life in ways he or she might not have wished, but it also may give the person time to reflect on relationship to assess beliefs and values, reaffirm or redesign what is most important and if necessary reorder his or her priorities.

If the person takes advantage of this opportunity he or she will find that it is possible to have even happier associations with family, friends and co-workers and to return to full and satisfying life.

Heart patients should keep off doctors, relatives and friends who want to make you a cardiac involved. You must consider a heart attack as a signal that there is something amiss with your pattern of living and as an opportunity to make the necessary changes in your way of life.

Sexual desire is often referred to as libido or drive, but is best understood as how often an individual wants to participate in sexual activity. Sexual desire involves a person's interest in sexuality, such as whether they seek sexual activity and the frequency of this activity, and whether they have sexual thoughts or fantasies. Libido involves attitude, and is related more to the mental state that motivates a person to pursue sex.

Sexual desire may be influenced by biological changes such as hormone imbalances, disease such as diabetes, and psychosocial influences such as relationship factors. Psychological disturbance such as depression may result in changes to sexual desire, as many learn responses such as the appropriateness of a situation to participate in sexual behaviour.

Sexual behaviours may also be motivated by factors such as anger or jealousy, which may not be related to actual sexual needs.

A person may engage in sexual activity without necessarily having any sexual desire, such as for financial reward or out of guilt. Alternatively when no partner is available a person may experience high levels of desire without actually engaging in sexual activity. Sexual arousal is a state, which involves the excitation in the sexual organs. Sexual arousal in women includes swelling of the labia and vaginal lubrication. Decreased lubrication may occur in postmenopausal women due to decrease in hormonal levels, and this may result in problems in sexual arousal. This may cause insertion of the penis difficult, painful and even impossible for some menopausal women. Factors, such as quality of the relationship with the partner may also influence arousal. Psychological factors that may contribute to sexual arousal include feelings of anxiety, depression, previous sexual behaviour and attitude before the onset of menopause.

The perceptions of body image and mid life issues are also important psychological factors. Women who experience intense mood swings during the menopause often find their sexual interest decline and even vanish. Anxiety symptoms such as palpitations, rapid breathing increased sweating can cause less sexual arousal.

Depressive symptoms such as fatigue decreased motivation and negative thoughts also effect sexual desire.

Psychologists have found that anxiety has been associated with a reduction in the frequency of sexual intercourse, while depression has been related to a decrease in sexual desire. Depression is associated with decreased likelihood of intercourse occurring than age and vaginal dryness due to menopause.

The role of body image has also been linked to the willingness of women to participate in sexual activity. While some women have a negative body image throughout their life, other women decide that they are sick of worrying about their body and have other things they would rather focus on by the time they get to midlife.

Psychologists have found that partners accounted more for reduced sexual activity than menopause. Cessation of sexual activity was often due to the attitude and the ability of the male partner to perform sexually. Often it is the male partner who is the initiator of sexual activity and with aging and poor health, his role as initiator may decrease. Different cultural attitudes specially eastern countries like Sri Lanka, also may influence a woman's willingness to mention sexual problems. Each woman will experience menopause and midlife in her own individual way. Cognitive behavioral therapy is helpful in treating desire and arousal issues in the menopausal woman.

We have often been told that we should drink eight cups of water a day. But does anyone know why?

The answer, is to maintain the body's proper water balance. Water is essential to life, it is present in all living body cells. If the body is to function properly, the body's daily output of water must be replenished. And research has shown that, for adults approximately eight cups of water are needed to maintain this healthful water balance. Even a physically inactive adult uses up eight cups of water daily, because water is the medium for virtually all the body's chemistry, and it is used constantly.

Water is basic to balanced nutrition. It helps in the digestive process to break up, soften, and transport food particles from stomach to intestines. Then the body's blood, which is 90 per cent water circulates nutrients.

Water controls body temperature through perspiration. Perspiration occurs to some degree even when one is not aware of it, each day the skin of even a sedentary person loses moisture equal to about two cups of water.

Water is a lubricant preventing friction between the body's joints and muscles, the same way oil prevents friction between machinery parts. During manual labour and many strenuous sports, the body is stretched, twisted, and bent in ways that wouldn't be possible if water weren't present. Water intake minimizes dehydration from sweating that can result from long periods of exercise. Water reduces stress on the circulatory system during sports activities, and it helps the blood carry energy providing carbohydrates to the body's cells.

During illness, greater water intake helps regulate body temperature and control fever. By using water for all its functions and losing water through perspiration and breathing, the body uses an average of three quarts each day. Most people consume approximately one quart in their daily diet, so where does the rest come from? In its simplest form, by drinking eight cups of water.

Weight watchers, Note: Sugar-and calorie-free water is the perfect beverage for dieters.

I got sort of a stomach bug, somewhere around October 2001 which made me go off food for sometime and which left a bad taste in my mouth. Following the stomach disorder I experienced pain in my legs and numbness. What started as a harmless pain developed into severe pain and my legs began to feel heavy. Then after numerous visits to doctors and medication, I was asked to enter hospital for a series of tests.

"You have got Guillein Barre Syndrome, it's a viral disease that affects the nervous system and you will have to take intensive physio therapy and there is no medicine for this disorder" the doctor said. I was rather confused since I have never heard of such an illness before. All I was told is it will take a very long time for me to come back to my normal self. While in hospital, I suddenly collapsed in the bathroom and I found I couldn't move without aid and the muscles on my legs became like bag of jelly. It has lost its firmness and my bones were jutting out. I needed someone to raise me from the chair. Yet my arms were o.k. and was able to attend to my needs.

I was given some vitamins and a transfusion of plasma. Since there is no medicine other than physio therapy, I came back home a semi vegetable. After I came home I felt as though my body was shutting down. First I lost control of my legs, then gradually my hands lost their functions. The fingers on my hands twisted in an awkward position. I became a cripple and was confined to the bed. I needed help for my daily activities. I couldn't chase even a fly on my nose. I went into severe depression, because I had no knowledge of this sickness.

I was desperate and my mind was so confused, it was like a worm eating its way through the fruit, so many questions crowded my mind.

I was totally dependent on others for my day to day activities. My arms and legs became so heavy it was simply not possible to move them. My entire body lost the firmness of muscles, and flesh was just hanging from my bones. My body was icy cold like that of frozen meat. I was told that it was due to lack of blood supply to the muscles. This sickness is also known as muscle malfunctioning.

We got the help of a physio therapist, who visited home. In spite of the physio therapy I was not showing any sign of progress. A friend of mine gave me the telephone number of an Ayurveda doctor. The doctors came home and after examining me said they will undertake the treatment. For forty days I was given a herbal oil massage every other day. With regular physio therapy and oil massages, I started recovering slowly. I got back the movements of my arms and legs. The first day when they propped me up to stand, I collapsed like a deflated balloon. Gradually I regained the use of my arms and legs.

I remember the first day I was put on the wheel-chair and taken out. Though I couldn't sit for a long time I enjoyed every moment of my wheel-chair ride. After months of lying down and staring at the ceiling, I was thrilled to see the plants, flowers, the blue sky and the birds flying. I was confined to the wheel-chair for nearly 6 months. I started walking with the aid. After almost two years since I got this deadly disease, now I walk unaided.

On my inquiry I was told that this sickness is affecting quite a number of people now. My message to the patients of Guillein Barre Syndrome is "Don't despair. You will recover but the recovery is frustratingly very very slow. Have patience and faith. Keep your spirits up and exercise your limbs regularly. You will be your self one day.

In simple terms, the phrase hiatus hernia describes a condition in which a part of the stomach has passed upwards into the chest cavity through a small opening in the diaphragm,the muscle that separates the chest from the stomach.

Everyone of us has an opening in the diaphragm to allow the oesophagus to reach the stomach in its normal position. However, what happens in a hiatus hernia is that for one reason or another, this normal opening becomes sufficiently weakened or enlarged so that a part of the stomach itself has been able to go through it.

Once a part of the stomach has passed through this opening, it can then become retained there as the oesophagus now acts as a clamp that stops the return of the protruding section to its former position. Although the very idea of having a part of a vital organ lodged in an area where it is not meant to be is obviously rather disturbing, quite often the condition leads to few if any symptoms, perhaps remaining blissfully unaware that they have a hiatus hernia.

Unfortunately, this lack of symptoms is not universal and for some people a hiatus hernia can lead to a wide variety of chronic and painful symptoms, the most common of which is heartburn - which can be defined as a discomfort or pain, typically burning in character, that the sufferer experiences in the general area of the breastbone. Generally,but not invariably, the sufferer will also be aware of a sensation that suggests that the pain is rising from the abdomen towards the throat. Additionally, heartburn may be marked by acid or bitter tasting fluid appearing in the mouth, this symptom is called acid reflex. It is important to be aware that despite its name, heartburn has nothing to do with the heart and the symptom in itself does not indicate heart disease of any kind.

Heartburn is, in fact, the direct result of acid from the stomach travelling the "wrong way" and entering the oesophagus. This, in turn, is caused by one of several factors or a combination of these, but all of them have the same net effect in that the sphincter - that's the name for a ring of muscles that surrounds an orifice and contracts to close it, acting like a valve - at the bottom of the oesophagus in either too weak to stop acid rising from the stomach or relaxes inappropriately. Known facts about hiatus hernia

* Many people have hiatus hernia but don't suffer from heartburn. That, of course, does not prove that a hiatus hernia does not cause heartburn, merely that it doesn't necessarily or always do so.

* Many sufferers from frequent or severe heartburn are found, upon investigation hiatus hernia is detected.

* In most cases heartburn, whether or not accompanied by a hiatus hernia, is the main troublesome symptom. This will either disappear or its severity will be greatly reduced when treatment is started.

Treatment in this context often includes lifestyle changes, such as choosing food more wisely, losing weight if overweight, and cutting down on or giving up alcohol and tobacco.

* Having hiatus hernia does not mean that you will also have heartburn or any other kind of digestive problems, but the presence of a hiatus hernia certainly increases the chances of heartburn.

* While it is important to be aware of the role that a hiatus hernia can play in predisposing you to heartburn, it is even more important to realise that having a hiatus hernia does not mean that you have to suffer heartburn as this is extremely uncomfortable and at times painful symptoms can usually be treated quite easily with generally excellent results.

" Hiatus hernia is a widespread health problem in Sri Lanka. If someone suffers from heartburn he or she should seek timely medical advice and it is also important to avoid foods, including garlic, peppermint, chocolate, coffee, all fatty foods, all fizzy drinks, spicy foods and tomatoes," says DR ROHITHA JAYAWARDENA, Consultant Physician in an interview with Sunday Observer reporter, Don Asoka Wijewardene.

According to Dr. Jayawardena, if someone suffers from heartburn he/she may or may not find it comforting to know that the overwhelming majority of cases heartburn, whether or not caused or exacerbated by a hiatus hernia, will often respond speedily to some simple and practical measures.

1. Avoid large meals - the fuller your stomach, the more likely acid reflex will occur. You should also try to eat slowly to avoid overloading the stomach.

2. Don't eat anything during the two hours just before going to bed. After you eat the stomach makes extra acid and lying down at that time is just asking for trouble.

3. You will be at greater risk of heartburn if you are overweight because this increases the pressure in the abdomen. Many chronic heartburn sufferers improved considerably after they went on a weight-losing diet.

4. You can improve the chances of the acid staying in your stomach at night by raising the head of your bed a few inches. Alternatively, you could use an extra pillow or two to ensure that your head is higher than your feet.

5. Avoid foods most likely to set off a coughing spell, such as peanuts and other nuts as well as smoking which could also cause coughing. Coughing strains your abdominal muscle and it cannot only exacerbate an existing hiatus hernia but even possibly leads to one.

5. Because the amount of pressure created on the oesophageal sphincter muscle is affected by the kind of food you eat. Some medical experts suggest you should avoid foods that lower this pressure as this makes the valve less effective. Foods known to have a pressure-lowering effect including all forms of caffeine-containing drinks and fatty foods.

6. Ginger root - available in capsule form, when taken after meals will help absorb excessive acid, so reducing the chances of acid reflex.

7. Substantial relief can be obtained from acid reactions by sipping a table spoonful of cider vinegar mixed in half glass of water during meals.

8. Bananas are a wonderful natural anti-acid - eat one or two when heart burn strikes. Seek out foods that help you avoid constipation as this will also reduce the symptoms of hiatus hernia because these can be triggered by having to strain unnecessarily during bowel movements.

Finally, should your symptoms fail to respond quickly to these self-help measures or your heartburn be persistent or start becoming more troublesome, consult your doctor because it's possible that some other ailment may be the cause of your problem and this may require a different kind of treatment.