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Female sexual dysfunction in diabetes

Women with type 2 diabetes may not report sexual dysfunction, or may not perceive it as a problem. Signs and symptoms may merge into a mélange of mood swings, cystitis, vaginitis, depression, vaginal dryness, and lack of lubrication and libido. Statistically speaking, diabetic women can frequently experience arousal, desire (17-85%), pain (1-66%) or lubrication-related problems (14-76%).1 Mechanisms behind these problems are listed below.

In the past, much research has focused on male sexual problems – in particular, erectile dysfunction (ED). This is because the signs and symptoms of male sexual dysfunction are more obvious and measurable than female problems, ED being a classical example. Furthermore, the pharmaceutical industry has developed effective treatments for male sexual dysfunction, supported by scientific research. 

This gender imbalance is gradually being addressed as more studies are being published on female sexual dysfunction. This lack of knowledge is not because of some perceived gender prejudice but more because the issues are generally more complex. Women’s sexuality is more multifaceted compared with men’s; their issues are rooted in biological, psychological and social factors that interact with each other. This makes the biological factors less clear than with men. The reasons why diabetic women can get sexual problems include age, BMI, duration of diabetes, glycaemic control, HbA1c levels, menopausal status, the use of hormonal and oral contraception, or even the presence of diabetic complications. 

Psychosocial factors often play a part in reducing sexual desire, namely adjustment to the diagnosis and the burden of living with a chronic disease, impaired body image and depression. One study found that depression is the most important risk factor for sexual problems in women and suggested that diabetic women should be screened for this condition.2 

They also commented that good diabetic control and psychological health may help to prevent sexual problems. You also need to be aware of the effect of antidepressants on sexual function. SSRIs, in particular, can cause delayed orgasm or even anorgasmia. In general, type 2 diabetes has a greater impact on women’s sexuality than type 1 diabetes. This may be related to the later onset of the type 2 compared with type 1, so age, menopausal status, the presence of other comorbidities and relationship issues may all play a part. Time will tell whether this reasoning will still stand up to scrutiny with the increasing number of children and young adults diagnosed with type 2 diabetes.

One of the most common causes of female sexual dysfunction, including diabetes, is vaginal dryness.3 About 15% of premenopausal and 57% of postmenopausal women can be affected. This can be upsetting even for women who are not sexually active. Some of the causes of vaginal dryness include:

  •  Advancing age.
  •  Hormonal changes. 
  •  Menopause.
  •  The contraceptive pill.
  •  Breastfeeding.
  •  Stress. 
  •  Diabetes.
  •  Inflammatory bowel disease.
  •  Chronic heart failure.
  •  Multiple sclerosis.
  •  Cancer treatments. 
  •  Antidepressants.

Other diabetes-related sexual problems include fungal and bacterial infections, but improvement in glycaemic control can reduce the risk of reinfection. Of importance is that recurrent vulvovaginal candidiasis can be a marker for diabetes. You should therefore opportunistically screen such patients (and those with vaginal dryness) for diabetes, so that those with a confirmed diagnosis can be holistically managed in order to achieve optimal glycaemic control. Similarly, women diagnosed with polycystic ovary syndrome have been found to have a high prevalence of diabetes. 

Another important problem for women is lack or reduced lubrication during intercourse. It is important to ask about the drug history as some medications, such as antidepressants, can cause this. It would be wrong to just stop the medication without assessing the reasoning for prescribing it in the first place, but there may be scope for reducing or changing the prescription. There are many and varied forms of lubricant, but in general, beware of ‘stimulating lubricants’ that may contain irritating ingredients such as capsicum (pepper), which may be fine for a younger woman with healthy vaginal mucosa but may be extremely irritant to, say, a menopausal mucosa, which may be very thin and friable.

Treatments for female sexual problems

Personal lubricants and vaginal moisturisers

A wide variety of personal lubricants are available as water-, oil- or silicone-based products, some of which are available on an NHS prescription. They are applied to the vulva and vagina prior to sex. Vaginal moisturisers tend to provide longer relief (2-3 days) by lowering the acidity and changing the endothelial fluid content. They rehydrate the dry mucosa by being absorbed into the tissue and adherence to the vaginal lining. Applying some to the penis during sex also acts as a very efficient tool in order to distribute the lubricant or moisturiser throughout the vagina.

Work by the World Health Organization has enabled recommendations for the correct osmolality for lubricants, as there is great variation. The figure of 380mOsm/kg was recommended in order to minimise epithelial damage. But because so few products achieved this target, an upper limit of 1200mOsm/kg was deemed acceptable in reality.4 Similarly, pH varies greatly in different lubricant brands. The healthy adult vaginal pH range is 3.8-4.5 and that for the rectum around 7.0. No single lubricant bridges both of these ranges. A value of three or less is thought to be unacceptable.5

Lubrication: what are the general expectations during sex? 

  •  Women are expected, and in general expect themselves, to produce a moderate amount of vaginal lubrication during sex.
  •  Women report that they prefer vaginal-penile intercourse to feel wetter.
  •  Women can generally orgasm more easily when sex is wetter.
  •  Women believe their partner prefers sex to feel more wet than dry.

PDE5Is

Phosphodiesterase type 5 inhibitors (PDE5Is) have been shown to be useful in diabetic women with sexual genital arousal disorder.6 Women were given tadalafil 5mg daily for 12 weeks. Results demonstrated a quality of life improvement, together with improvement in sexual genital arousal and orgasm, sexual enjoyment and satisfaction determined by frequency of sexual activity and frequency of sexual thoughts and fantasy. Women also reported that their dyspareunia decreased.

My clinical experience is that women who are (and need to continue) taking antidepressants can achieve improvement in sexual function by taking PDE5Is in addition. 

Oestrogens

Many diabetic women can be helped by applying local topical oestrogens to the periurethral area and vagina as treatment for genitourinary syndrome of the menopause. Symptoms such as nocturia, urinary infections, frequency and urgency can improve. The NICE guideline for the menopause commented to ‘advise women with vaginal dryness that moisturisers and lubricants can be used alone or in addition to vaginal oestrogen’.7

In women where stress is thought to be a predominant cause of the sexual problem, I have found the herbal medication Rhodiola rosea, taken by mouth, is useful taken once in the morning and again at lunchtime. It is essential that it has a Traditional Herbal Registration logo on the packet that assures quality, safety and efficacy assessments. Additionally, rodent research has backed up the clinical experience.

Physical devices such as vibrators (that come in a variety of shapes and sizes) and vacuum therapy certainly can play their part in helping women to achieve arousal and orgasm.

Dr David Edwards is a GP with special interest in sexual dysfunction in Oxfordshire. He is a past president of the British Society for Sexual Medicine, chair of the Primary Care Testosterone Advisory Group and vice chair of trustees of the College Of Sexual and Relationship Therapists

References

  1. Kanavos et al. Diabetes expenditure, burden of disease and management in 5 EU Countries. London School
  2. Giraldi A, Kristensen E. ESSM today. 2012;25 :7-8
  3. Edwards D, Panay N. Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturiser composition? Climacteric 2015; 19:723-35
  4. World Health Organisation. Use and procurement of additional lubricants for male and female condoms. WHO/UNFPA/FHI360; 2012
  5. Cunha AR et al. Characterisation of commercially available vaginal lubricants: a safety perspective. Pharmaceutics 2014; 6:530-42
  6. Rees M et al. Br J Sex Med 2009 ;32:4-6
  7. NICE. NG23: Menopause. London; NICE: 2015

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