My friend Stephen suggested I write about spring.

"I'm a cardiologist, not a weather man," I noted.

"Write about what people do in the spring," he replied. "It's a time of feeling fresh and rejuvenated. People are excited and think about sex."

"But, Stephen, I'm a cardiologist. I give drugs to people that ruin their sex lives."

And, I suppose, I give drugs to people to help fix the problem, too. In truth, the drugs I prescribe probably have less to do with the sexual dysfunction than do other, larger issues. Someone who can't breathe or gets chest pain when they walk to the bathroom is not really going to be in the mood for a kiss on the cheek, much less anything more. And sudden increases in heart rate are not the best thing in the first few weeks after a heart attack. But once a heart attack has healed, let the fireworks begin.

Which is where the frustration can begin. For men, the sexual response is generally a plumbing issue. Proper response means more blood flow in and less blood flow out. If a man has a blockage in his coronary artery, there's a good probability he'll also have a blockage in his penile artery - a blockage that decreases the inflow of blood from a rushing Niagara Falls into a small trickle. (I once read that the name Viagra comes from the words "virile" and "Niagara.")

Viagra, Cialis and Levitra are drugs that increase the inflow of blood. As it turns out, they are relatively safe in heart disease, provided the man doesn't take nitroglycerin or long acting nitrates with them. And since nitrates or nitroglycerin never have been shown to save lives, most men would rather just throw out their nitro, which they aren't using anyway.

Men typically don't like to come out and discuss the issue. Often, when I ask whether there's a problem with erectile dysfunction, the man will mumble something I can't hear while his wife will vigorously nod and mouth the words "YES." The embarrassment is, of course, misplaced. Most men aren't embarrassed about a blockage in their coronary artery, so why be embarrassed about a blockage in their penile artery? It's only plumbing.

Of course, blood flow increases in response to emotion and feeling, both of which are often seriously limited when someone gets a diagnosis of heart disease.

According to my gynecology colleagues, bloodflow is rarely a problem for women. Indeed Viagra has never been shown to improve female sexual response. I've often wondered whether women have less sexual dysfunction or whether they are just less vocal about it. Women are more complex, combining physiology and emotion in ways less easily understood.

I still have a lot of patients who decide to give up intimacy after a heart attack simply because they (wrongly) believe that sex is somehow bad for their heart. It's a twisted sort of logic, giving up something you like as a sort of self-sacrifice to make yourself physiologically better. When, at the one-month visit after a stent, a couple sheepishly asks me when they can resume a sex life, I generally say what I once heard an older, now retired cardiologist say: "I'd rather you waited 'til you leave the office."