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Sexual Wellness

by Laura Hieronymus, M.S.Ed., A.P.R.N., B.C.-A.D.M., C.D.E., and Lawrence Maguire, M.D.

"Intimacy is being seen and known as the person you truly are."—Amy Bloom

Researchers believe that up to 50% of people with diabetes will experience some sort of sexual dysfunction at some point. But even if diabetes doesn’t directly cause sexual dysfunction, other diabetes-related health issues can influence your sexual desire and may be a threat to intimacy within a relationship. It is important for you to be educated and aware of these issues, both to prevent health or sexual problems as much as possible and to be prepared to cope if they arise.

Types of sexual problems
Sex experts have divided sexual dysfunction disorders into four categories: desire disorders, arousal disorders, orgasm disorders, and pain disorders. One type of disorder can and often does coexist with another. None of these types of disorders is unique to people with diabetes, but diabetes can contribute to some of them. Sexual problems can occur at any stage in a person’s life and can occur suddenly or gradually over time.

Desire disorders. Decreased libido, or a persistent lack of desire for sexual activity, is called a desire disorder. Common predisposing factors include changes in testosterone production (in both men and women) and a decrease in estrogen level in women, most commonly associated with menopause. Psychological or relationship problems can also lead to desire disorders.

Testosterone is a sex hormone that plays an important role in puberty. In men, testosterone is produced primarily in the testes, the reproductive glands that also produce sperm. As men age, their testosterone level tends to decrease, along with their sex drive. In men with diabetes, however, a decrease in testosterone production may occur at a much younger age. Men with diabetes as young as 45 are twice as likely to have a low testosterone level as men who don’t have diabetes.

In women, small amounts of testosterone are produced primarily by the ovaries and adrenal glands. While the role of testosterone in women is poorly understood, it is believed to have an effect on sexual desire and function. Menopause and certain medical conditions may cause a woman to have a low testosterone level, possibly contributing to lowered sexual desire.

Women with polycystic ovary syndrome (PCOS), a disorder characterized by menstrual irregularities and infertility, however, tend to have the opposite problem: a high testosterone level. Like Type 2 diabetes, PCOS is associated with insulin resistance, in which the body is unable to use insulin efficiently. In fact, about 50% of women with PCOS eventually develop Type 2 diabetes.

A high testosterone level in a woman—whether or not she has PCOS—can cause development of male sex characteristics, including an increase in body hair and facial hair, a deepening of the voice, male-pattern baldness, and clitoral enlargement. High testosterone is not directly associated with a lack of sexual desire, but the physical changes it can cause can affect a woman’s self-esteem and cause her to feel unattractive and sexually undesirable.

The decline in estrogen levels that occurs with menopause similarly may not directly affect a woman’s level of sexual desire, but other aspects of menopause, such as hot flashes, may affect how she feels about sex. In some women, hot flashes can contribute to fatigue and sleep deprivation. In others, hot flashes can alter mood and consequently affect the quality of their sexual relationship.

In addition to these hormonal changes, the following can contribute to lack of sexual desire:

• Physical changes that often occur with aging, including lack of energy, loss of strength, and stiffness with body movement, can affect both sexual function and sexual desire.
• Fatigue or tiredness, whatever its cause, can profoundly affect a person’s interest in sexual activity.
• Pregnancy and the tiredness, discomfort, changes in body image, and changes in hormone levels that go with it can lower sexual desire.
• A well-known side effect of antidepressants in the selective serotonin reuptake inhibitor (SSRI) class is reduced sexual desire in both men and women. The SSRIs include fluoxetine (brand name Prozac), sertraline (Zoloft), and paroxetine (Paxil).
• Depression can contribute to a lack of interest in sex or lack of energy associated with sexual desire. Depression is common among those living with a chronic illness such as diabetes.

Arousal disorders. The inability to become aroused or to maintain sufficient sexual excitement is called an arousal disorder. In women, sexual arousal disorder involves an inability to attain or maintain swelling and lubrication of the genitals. In men, it involves difficulty attaining or maintaining an erection. Arousal disorder may appear to stem from an avoidance or aversion to sexual contact with a partner. But in fact, the roots of the problem can be physical as well as psychological.

Orgasm disorders. A persistent delay in or absence of orgasm following a normal sexual excitement phase can occur in both men and women. Use of SSRIs commonly contributes to this problem. (If you have been prescribed one of these drugs, however, do not discontinue it without first consulting your prescriber.) Diabetic neuropathy (nerve damage associated with diabetes) may also contribute to the lack of ability to achieve orgasm.

Pain disorders. Pain associated with sex is more common in women than in men, but it can affect both sexes. Its causes can be physical, psychological, or both. In some cases, women experience pain with intercourse because of vaginismus, an involuntary spasm of the vaginal wall muscles. While the cause of vaginismus is not clear, trauma such as rape or abuse may play a role.

Poor lubrication and vaginal dryness can also contribute to painful intercourse in women. The possible causes of poor lubrication and vaginal dryness are many, and they include the hormonal changes that occur with pregnancy and breast-feeding. With menopause and the accompanying decrease in estrogen production, the vaginal lining becomes thinner, which can cause vaginal dryness and pain with sexual activity. In women with diabetes, these symptoms can often be exaggerated, especially during periods of less than ideal blood glucose control.

If you or your partner is experiencing pain during sex that appears to be related to vaginal dryness or irritation, your health-care professional may suggest taking time for adequate stimulation prior to intercourse, using a vaginal estrogen cream or water-based lubricant, and avoiding contraceptive foams and creams that may be irritating to the vaginal lining.

Is it my diabetes?
The physical health issues that are commonly associated with diabetes can contribute to sexual problems, so when any form of sexual dysfunction develops in a person with diabetes, it should be considered as a possible cause. However, diabetes should not automatically be assumed to be the problem; other potentially relevant health issues, many of which are not diabetes-specific, should be examined as well.

Most diabetes complications are related to high blood glucose, and sexual problems are no exception. In the short term, high blood glucose can negatively affect your energy level as well as your mood, which can cause any relationship to suffer. Your body’s cells require glucose for energy; high blood glucose levels usually indicate that glucose is not being moved into your body’s cells, and you therefore have less energy than usual. The higher your blood glucose levels, the more tired you will typically feel.

In addition, when blood glucose levels are high, you may feel irritable or cranky. Other symptoms of high blood glucose such as frequent urination, feeling thirsty, and having blurry vision can be annoying and preoccupying, keeping you from any preferred behavior, including spending time with your partner.

Persistent high blood glucose levels can increase the likelihood of infections in the urinary tract, vagina, and penis, which can obviously put a damper on intimate moments.

Over the long term, blood glucose levels that remain high and uncontrolled contribute to neuropathy (nerve damage) and blood vessel damage leading to impaired blood circulation. Both of these can affect the body’s response to sexual stimulation, leading to erectile dysfunction in more than one in three men with diabetes as well as lubrication problems related to sexual function in up to 60% of women with diabetes.

Impaired circulation. High blood glucose, high blood pressure, and high cholesterol all raise the risk of developing atherosclerosis, or an accumulation of fatty material under the inner lining of the arteries. Atherosclerosis raises the risk of having a heart attack or stroke, and it can also lead to impotence and problems with arousal and orgasm (in men and women) if it impedes blood flow to the genital region.

Neuropathy. As many as 50% of people with diabetes eventually develop some type of nerve damage. While damage to the peripheral nerves is associated with burning, tingling, or numbness in the feet, damage to the nerves that regulate involuntary functions, such as those that relate to response or excitement from sexual stimulation, can contribute to sexual problems. The function of nerve fibers plays a vital role in one’s ability to experience sexual pleasure.

Prevention
Preventing diabetes complications, including sexual complications, involves controlling your blood glucose, blood pressure, and blood lipid levels. If your glycosylated hemoglobin (HbA1c) level is currently higher than 7% (or higher than the HbA1c goal recommended by your diabetes care provider), your blood pressure higher than 130/80 mm Hg, your low-density lipoprotein (LDL) cholesterol 100 mg/dl or above, or your triglyceride level 150 mg/dl or above, speak to your provider about bringing these levels into the recommended ranges.

Take a proactive role in your diabetes health by monitoring your blood glucose levels, taking action when they are too high (based on medical advice), and communicating regularly with your diabetes care team. Maintaining excellent health takes hard work, but the payoffs are many, including feeling better mentally and physically.

Getting help
If you’re experiencing persistent sexual difficulties, speak to your diabetes care provider about it. Based on your description of the difficulties you’re having as well as your previous medical history, including any drugs you may be taking, your provider may be able to rule out some possible causes or identify some likely ones. He may choose to treat you himself or may refer you to a specialist such as a urologist for care. If your diabetes control appears to be a contributing factor, your provider may recommend changes in your treatment plan or refer you to an endocrinologist or possibly to a diabetes educator for education and skills training. If your sexual problem appears to be primarily psychological in nature or your provider believes you may be experiencing depression, he may refer you to a mental health care provider such as a psychiatrist or psychologist for therapy and, if needed, antidepressant drug therapy.

No matter what their cause, sexual problems tend to have profound effects on emotional well-being and on relationships. Talking with a licensed psychotherapist or seeking the help of a marriage and family therapist can help you cope as you seek medical help or adjust to changes in your sexual function. In many cases, psychological counseling along with treatment of physical factors contributing to sexual problems offers the best solution to management.

Maintaining your relationship
While you seek medical help or mental health care, it’s important to keep the lines of communication open with your partner. Talking frankly about the problems you’re experiencing and your feelings about them, as well as listening to what your partner has to say, will most likely bring you closer. When you talk, keep in mind that what makes a relationship satisfying for the people involved is really up to them—not to some notion about what intimate relationships should be.

Recognizing the fact that women and men commonly have different perspectives regarding intimate relationships may be helpful. Men typically want a partner who is willing and interested in a sexual relationship, and they often associate intimacy with sexual contact. Women, on the other hand, tend to feel closer to a partner who listens to them and most often connect sexual intimacy with love.

So let that special person see and know who you truly are, as well as what you want within the relationship. People who understand the needs of their partners—and recognize that those needs might be different from their own—have the best chance for creating longer-lasting, more satisfying, intimate relationships.

For more online information about sexual health, see "Read More About It."

Laura Hieronymus is the program coordinator for an American Diabetes Association–recognized education service, and Lawrence Maguire is a practicing internist. They are diabetes care and education providers at Drs. Borders & Associates, PSC, in Lexington, Kentucky.

Statements and opinions expressed on this Web site are those of the authors and not necessarily those of the publishers or advertisers. The information provided on this Web site should not be construed as medical instruction. Consult appropriate health-care professionals before taking action based on this information.