COMMENTARY

Female Sexual Dysfunction: If We Don't Ask, We Won't Know

Alice Cheng, MD; Mark Harmel, MPH

Disclosures

June 18, 2020

This transcript has been edited for clarity.

Female sexual dysfunction is common in people living with type 1 or type 2 diabetes, with 35%-71% of women living with either type 1 or type 2 diabetes experiencing female sexual dysfunction. And the problem is that we are not asking about it.

Why do women with diabetes get female sexual dysfunction? The reasons are fairly obvious. Things such as atherosclerosis, neuropathy, mental health issues, body image issues—all of these things are common in women living with diabetes, and all of these things can lead to female sexual dysfunction. But as I said earlier, we are not asking, and that's a very important thing for us to start doing, because almost three quarters of the women who have been asked would prefer that their healthcare team bring up this subject.

How Should I Bring It Up?

So then the question becomes, "How do we bring this subject up?" It's not something that we were necessarily trained to do.

One way to do it is to first remember that this is something we ought to be asking about, so we can start by normalizing the conversation. We can use a ubiquity-style question, saying, "Many women with diabetes experience sexual problems. Is this something that you would like to talk about?" This way, you're normalizing it and you're also asking for permission to discuss it.

If a woman does say that she has an issue, then the other things we need to do are to model the language that she can use and to normalize her experience, as well as to listen in an empathetic way.

Once we've identified the female sexual dysfunction, we may wish to categorize it into different types. They can be issues with desire, arousal, or orgasm, which are the three phases of the sexual response cycle. Depending on what you identify, you would then ask different types of questions.

The overall model to take is a biopsychosocial approach, recognizing that many things can contribute to the female sexual dysfunction disorder that the patient is experiencing. If you identify a modifiable factor, then of course doing whatever is necessary to change it is what's going to help her. However, in the case of hypoactive sexual desire disorder, pharmacologic therapies may be necessary.

Nonpharmacologic Therapies

Let's talk about some of the nonpharmacologic therapies that we ought to be thinking about. Education is a huge component of this, because as I said earlier, this is something we do not talk about enough. There are sex therapies that are available out there. Local therapies may be appropriate to consider, such as lubricants or dilators. For women who are postmenopausal and may be experiencing atrophic vaginitis, estrogen creams used locally may be very beneficial. And let's not forget about lifestyle modifications that can also have a significant impact.

Pharmacologic Therapies

Two pharmacologic therapies have been approved by the FDA for the treatment of hypoactive sexual desire disorder: flibanserin and bremelanotide.

Flibanserin works on serotonin receptors and effectively increases norepinephrine and dopamine, and decreases serotonin. Bremelanotide works on the melanocortin-4 receptor as an agonist, therefore increasing the activity of the melanocortin, allowing for an increase in sexual desire. Both of these therapies are approved by the FDA for the treatment of hypoactive sexual desire disorder in premenopausal women.

Other therapies that could be offered would be off-label. For example, bupropion or buspirone could be used off-label in order to treat hypoactive sexual desire disorder. In a woman who is postmenopausal, testosterone could be used off-label in order to achieve levels of testosterone that are within normal female physiologic levels. Other therapies are being researched for hypoactive sexual desire disorder, which is one of the more common disorders that may occur in female sexual dysfunction.

The most important thing to take away is that education is a critical component, as well as sex therapy (which can be very helpful), local therapies, and nonpharmacologic therapies. And then, of course, pharmacologic therapies are also on the list.

But if we don't ask, we won't know. It's critical to remember that female sexual dysfunction is common in diabetes, and it needs to become one of the routine things that we ask about.

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