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The management of diabetes is multifaceted, often requiring the collaboration of a multidisciplinary team of providers. While sexual side effects of diabetes are not commonly discussed during patient visits, there is a correlation between the presence of diabetes and frequent sexual dysfunction in women.
Ob-gyns are well positioned to assist in opening a dialogue with female patients about their sexual health. In a recent review article by Winkley et al, it was determined that even though sexual dysfunction causes substantial distress and negatively impacts quality of life, there is significant under-reporting of its incidence in woman with diabetes, with a disparity seen between spontaneous reports of sexual dysfunction compared with screen-detected sexual dysfunction in research trials.1
Sexual dysfunction is an amalgamation of physical and psychological issues, including inadequate communication between sexual partners, poor body image, job loss, and medical considerations. Updates to the Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) reduced the number of diagnostic categories of sexual dysfunction from 4 to 3, along with introducing a 6-month minimum duration of symptoms for a formal diagnosis since some sexual disorders may be temporary or stress-induced. In order to determine if a sexual disorder is temporary, a deeper exploration of what is happening needs to take place. The challenge is that this assessment can be a sensitive topic for women and clinicians to raise and discuss during clinical consultation.1
The American Diabetes Association notes that the lack of conversations surrounding this issue is 2-fold. Only 19% of women with diabetes have spoken with their doctor about sexual problems, and doctors aren’t comfortable delving into their patient’s sexual performance and health.2 According to 1 study, only 40% of ob-gyns routinely ask their patients about sexual problems.3
With limited physician/patient dialogue, all members of the diabetes interprofessional team need to increase their awareness that sexual health, albeit an uncomfortable subject, needs to be discussed more frequently with patients.
“Diabetes specialists are not used to asking women about sexual functioning as they normally are focused on pregnancy and contraception,” said Kirsty Winkley, PhD, a diabetes specialist nurse and health psychologist at King's College London & Florence Nightingale Faculty of Nursing & Midwifery and co-author of the recent review article. “They may be worried they could offend a woman, especially if women with diabetes are unaware that some of their problems with sex are related to diabetes.”
The recent review article notes that there are several screening questionnaires that can be leveraged as tools to open the lines of communication when determining if sexual dysfunction is present among women with diabetes. These include the Female Sexual Function Index (FSFI), the Brief Sexual Symptom Checklist for Women (BSSC-W) and the Changes in Sexual Functioning Questionnaire 14 (CSFQ-14). However, use of these tools is not widespread in the clinical setting.
“In the U.K. at least, these are not routinely used,” Winkley said. “They have been used in a research context. However, it might be easier for diabetes specialists to raise the issue if women complete the scales or perhaps are provided with some information on the association between sexual dysfunction and diabetes.”
There are several indicators that demonstrate that women with diabetes are at greater risk for sexual dysfunction. Glucose levels can impact sexual intercourse by altering vaginal lubrication, causing pain during sex and affecting the ability to orgasm. Depression, which is noted with increased prevalence in all patients with diabetes, can be linked to diminished sexual drive. General fatigue or having sex without concerns of hypoglycemia, as well as a negative body image due to the use of medical devices to manage the disease (insulin pumps, injection site scarring), can be additional troubling matters for patients.
Several treatment options have demonstrated the ability to reduce levels of sexual dysfunction in women with diabetes, including pharmacological interventions (phosphodiesterase 5 [PDE 5] inhibitors, hormone replacement or anti-depressant therapy), non-pharmacologic interventions (weight loss, psychological interventions) and sexual health information guides utilized as part of clinical consultations. Once sexual dysfunction is identified in a patient with diabetes, shared decision-making efforts can be put into place to reduce or ease the negative aspects of sexual dysfunction that are impacting these women and their quality of life.
Part of that mindset needs to include the consideration of the patient as a whole entity. The Diabetes Care for You (DCFY) service, which was developed in accordance with National Health Service care guidelines in the United Kingdom, combines diabetes and psychotherapy services. The DCFY service incorporates the use of patient health questionnaires with improvements in diabetes self-management to address overall well-being as part of disease management. Validating the value of this model, the recognition of sexual dysfunction in women with diabetes within this service was particularly commended when DCFY won the 2019 UK Quality in Care (QiC Diabetes) award under the Mind and Body Healthy Together category.1
Continued improvements in the care of women with diabetes enduring sexual dysfunction warrants emphasis. Winkley offered that continuing the educational efforts is an ongoing necessity. “By raising awareness of the issue, I hope that this may lead to more research and better treatment and support for women with diabetes,” Winkley said. “Women's health issues in general need to be given more attention.”