COMMENTARY

Let's Talk About Sex: Women With Diabetes Often Lose Interest

Sharon J. Parish, MD; Mark Harmel, MPH, CDCES

Disclosures

July 26, 2022

This transcript has been edited for clarity.

Many women with type 1 and type 2 diabetes have sexual problems. In fact, up to approximately one third of women experience complaints of sexual desire, arousal, and even pain with sexual activity or just pareunia related to a variety of conditions, including the vulval and vaginal changes associated with menopause and beyond.

The most common complaints in women are related to desire and interest in sexual activity, as well as changes in genital sexual arousal or responsiveness and their orgasmic capacity. These problems occur in an age-related manner and sometimes in the context of biopsychosocial factors or physical changes associated with diabetes and diabetic conditions.

Although there are biologic factors, probably the most important factors affecting the sexuality of women with diabetes has to do with their social and relational context, as well as their disease adaptation and their self-image and feelings about themselves related to diabetes. For example, being anxious or worried about diabetes management, getting anxious or becoming hypoglycemic during the sexual event, worrying about how the apparatus might impact the way they look toward their partner, or their comfort during sexual activity could all be factors.

Probably the most important psychological or psychiatric factor is depression and its association with the disease state and its complications. This is an area for intervention that we could really focus on in our patients.

Many of us don't know about these sexual problems in our patients with diabetes because they don't raise them spontaneously. Female patients, hands down, diabetic and otherwise, really prefer the healthcare provider to ask.

Now, this may be a little bit awkward, so I recommend that you think about introducing it or giving a warning shot or framing it with something we call a ubiquity statement, such as, "Many women with diabetes have changes in their sexual function. How about you?" or, "Many women with diabetes notice decreases or differences in lubrication after menopause. Has that affected you?"

If a person answers yes, then you want to validate that and ask about other sexual concerns so that you have the full picture. "How is your sex drive? Are you able to get aroused? Do you need more stimulation? Can you reach orgasm? Are you having pain?" Then you want to use an open-ended inquiry to allow or encourage the woman to tell you more about the situation and its impact on her own sexual function and on her relationship.

Although there is some research on the biologic factors that affect diabetes in general — they affect the neurologic, vascular, and hormonal systems — and the potential role that these impairments may play on the sexual function of diabetic women, the strongest evidence for lifestyle intervention has to do with improving the psychosocial factors that I mentioned.

We can counsel patients to improve cardiovascular risk factors and neurologic function, exercise, diet, particularly the Mediterranean diet, weight loss, improving physical and sexual self-esteem by being stronger, with muscular development, and improving bone health. All of these things can have a feedforward effect on overall body image, self-image, enthusiasm, and energy for sex and sexual function, specifically.

There is a collection of treatments available for women, both in premenopausal and postmenopausal ages, to treat sexual disorders. For sexual desire in premenopausal women and women of late reproductive age, there are two FDA-approved drugs that both are centrally acting that can help with sexual desire and sexual responsiveness.

Flibanserin is a daily, on-demand serotonin drug with mixed receptor agonist and antagonistic effects that improves overall sexual desire. Bremelanotide is given on demand and works through the dopamine melanocortin system to improve sexual receptiveness and response of sexual desires in event-related experience. As I mentioned, it is given on demand, but it has a feedforward effect in that it overall improves the interest and desire for sex. For women with diabetes, there's no specific research on these medications, but they can potentially be helpful in the right populations.

We also have a fair amount of evidence supporting the role of androgen or testosterone replacement for postmenopausal women with distress and low sexual desire. There's no specific research on women with diabetes, but also no clear reason why it would be contraindicated with careful monitoring and dose adjustment, as would be done in any postmenopausal woman.

Finally, as I mentioned, sexual pain related to decreased lubrication and vulvovaginal changes after menopause can significantly affect the sex lives of postmenopausal women. We want to learn about and treat these changes related to vulvovaginal atrophy and what's called genitourinary syndrome with menopause.

We can offer specific nonhormonal changes, such as suggesting either oil- or water-based lubricants with sexual activity and recommending moisturizers that are used on an intermittent basis, such as two or three times a week to improve overall vaginal moisture, independent of sexual activity. We can also recommend regular sexual activity, which can help improve and condition the vulvovaginal tissue and help condition the elasticity in conjunction with lubricants and moisturizers.

For women who don't respond to the nonpharmacologic interventions, such as lubricants and moisturizers, there are an array of low-dose local — meaning given just on the skin — estrogen products that can be prescribed in a variety of ways. There are creams, inserts, tablets, and a ring, and all of them can really help with reconditioning or resurfacing the vulvovaginal tissue after menopause.

They're minimally absorbed and therefore, although they carry the estrogen-class labeling, are thought to be quite safe when it comes to some of the concerns that we have with systemic estrogen therapy. There's also an intravaginal DHEA [dehydroepiandrosterone] suppository and an oral SERM [selective estrogen receptor modulator] that can be used to treat vulvovaginal atrophy and genitourinary symptoms after menopause.

Finally, it's important for us to understand the resources in our community. We can refer patients to sexual medicine specialists or gynecologists who treat these conditions and particularly have an expertise or an interest in treating vulvovaginal atrophy and improving sexual function.

We can refer to psychological counselors. There is some evidence supporting the use of mindfulness-based cognitive-behavioral therapy for improving low desire and other sexual functions in women. We can refer to psychological and sex therapists as well as couples therapists who can help with the relational and social factors that I mentioned. Also, pelvic floor physical therapists may be helpful for patients dealing with an array of problems related to sexual pain.

In sum, it's important for us to understand that when treating women with diabetes, there is an array of biologic, psychological, social, and cultural factors that impact sexual function. Behavioral and lifestyle interventions as well as intervening with these factors that are amenable to intervention on a biological level can really help our patients.

Even if you don't have the time, specific interest, or capacity in your practice to manage these problems, the most important thing you can do is ask. Patients want you to raise the topic, identify the problems, and figure out who in your community can provide the resources that can offer the treatments that I've discussed today.

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