Key Points
• While many health practitioners are aware of diabetes related sexual dysfuntion in men, problems women face are not often discussed.
• Diabetes related sexual dysfunction in women can include low libido, vaginal dryness and higher rates of infection
• Establishing a healthy BGL, exercising, eating well and getting a good nights sleep can help mitigate complications

I am enormously impressed by the breadth of knowledge of diabetes nurse educators (DNE) who navigate their patients’ complex array of complications with skill and compassion.  Diabetes is a prevalent chronic condition causing ill health and distress to an ever-increasing proportion of Australians1.

Diabetes nurse educators, in conjunction with wonderful diabetes podiatrists working in a hospital outpatient department, taught me about the myriad physiological effects of diabetes mellitus. Their instruction was to prepare me to coordinate a randomized controlled trial (RCT) studying the way in which general practitioners (GPs) managed diabetes complications in the community. Participants were recruited from a representative population survey, enabling us to speak to people from both metropolitan and regional areas of the state. The study method was multi-faceted, including a thorough cross-sectional assessment of patients' complications; an interview with their GPs; and another interview with participants themselves about how having type 2 diabetes had an impact on their quality of life. A broad brief indeed: amassing these data was described by one of the chief investigators of the project as “a herculean task.”

Later when I taught public health at university, I used the methodological framework as an example of how not to design a research project. Academics and health bureaucrats designing such studies have not often been “on the ground” researchers themselves, and may not appreciate the person-power and time it takes to, colloquially-speaking, “bring this baby home.”  

Nevertheless the project gleaned a wealth of useful information about the management of diabetes complications. Being a “people person” I particularly enjoyed interviews with participants. They vividly described the constraints of their dietary regimen, their battles with weight, and the bewildering array of medical appointments to specialists that seemed never-ending! I met inspirational people including a man in his 70s who had lost a section of his sternum to osteomyelitis after cardiac surgery. With a lovely ironic smile he dismissed his health issues as “just life.” He was dignified, gracious and had beautiful old-world manners. I also met a woman, whose diabetes coexisted with a debilitating systemic arthropathy, restricting her ability to walk; she spoke animatedly about her passion for swimming, the one form of exercise she could pursue daily to control her levels of blood glucose (BGL).      

When we arrived at the section of the interview dealing with sexual health, most participants were surprisingly frank with me, relieved to have an opportunity to discuss this important aspect of their lives. I had been aware of the sexual dysfunction that could affect men with diabetes due to neuropathic and vascular changes: the inability to have or maintain an erection2, problems with ejaculation, and the psychological sequelae. One of the trial participants, for example, a handsome man in his 40s, tearfully described his ongoing fear that his wife would leave him. He was no longer easily able to maintain an erection. He struggled to afford treatment for monthly penile injections to enable him to have intercourse with his wife. The anguish and depression this caused him was painfully clear.  

I was, however, entirely ignorant of the impact of diabetes on the sex lives of women. I was stunned by the outpouring of angst from participants, a number of whom had never discussed the issue with a health sector person before. In some cases their GPs had not asked them about their intimate lives, and they were reluctant to raise the subject themselves. Some women felt that their sexuality “got lost” in the constant round of checks of blood glucose, kidneys, eyes, feet, and heart. Women who had previously had joyful sex lives were distressed by their incremental anorgasmia, and/or lack of libido. They were sometimes unaware that diabetes could have a bearing on their sexuality. Some simply perceived the loss of interest in sex as part of the natural process of aging; the prevailing wisdom, after all, was that diminished libido was a normal facet of being middle aged.

Though we know a great deal more about the sexual dysfunction of men with diabetes than women, there is increasing research evidence for the association between diabetes and sexual dysfunction in women. Journal articles ubiquitously cite the need for more research to redress the gender imbalance. 

There are ways women with diabetes can maximise their chances of maintaining an active and fulfilling sex life. Roszler, Rice and Elders (2007) describe a range of symptoms including vaginal dryness, which may be associated with low blood flow to the vagina, and/or neuropathy.  Higher rates of yeast and bladder infections occur in women with diabetes, and bacteria are attracted to higher blood glucose levels. This highlights the fundamental tenet for the mitigation of all diabetes complications: establishing and maintaining healthy blood glucose through sound diet, exercise and adequate sleep. The authors also advocate the use of lubricants to ameliorate vaginal dryness.

Though it sounds less than erotic, women are urged to take their BGL prior to making love to avoid a sudden plummeting of blood sugar during the process, and the sweating, irritability and distress hypoglycaemia can cause. They also suggest keeping fruit drinks at the bedside in case it occurs.

They point out that having sex can be the equivalent of an exercise workout, orgasm being a full-body response using muscles, nerves, energy and blood sugar (Roszler, Rice and Elders, 2007). The analogy echoes advice diabetes nurse educators offer patients before they go to the gym or pursue other forms of exercise. Why not before the life-affirming exercise of having sex?

Most importantly, women with diabetes are urged not to accept the demise of their intimate lives as an inevitable consequence of having diabetes, and to seek help by speaking candidly to their health care providers about it. We all need intimacy and love. What better way to expend energy and stay well?            

References:
1. AIHW (2013). Diabetes and disability: impairments, activity limitations, participation restrictions and comorbidities. Diabetes series no. 20. Cat. no. CVD 63. Canberra: AIHW.
2. Fonseca V, Seftel A, Denne J, Fredlund P (2004). Impact of Diabetes Mellitus on the Severity of Erectile Dysfunction and Response to Treatment: analysis of data from Tadalafil clinical trials. Diabetologia (2004) 47:1914–1923
DOI 10.1007/s00125-004-1549-6 Cited 17th January 2015.
Pontirole E, Cortelazzi D, Morabito A (2013). Female Sexual Dysfunction and Diabetes: A Systematic Review and Meta-Analysis. J Sex Med. 2013 Apr;10(4):1044-51. doi: 10.1111/jsm.12065. Epub 2013 Jan 24.
http://www.ncbi.nlm.nih.gov/pubmed/23347454  Cited 24th January 2015
Roszler J, Rice D, Elders J (2007). Sex and Diabetes: for Him and Her. American Diabetes Association Inc. USA.