If you have diabetes you have probably had conversations with your healthcare professional (doctor, nurse practitioner, physician’s assistant, nurse, dietitian) about many of your concerns regarding the complications of diabetes. You likely discussed your heart health and circulation, kidney function, vision, foot care and possible neuropathy (disease of the nerves). I bet you also reviewed your latest lab results for cholesterol and Alc. Maybe you planned new management strategies for the coming weeks and months, such as joining the water aerobics group or trying the new walking path. But did you talk about sexual function? Did your healthcare professional ask about the quality of your erection (men) or whether arousal and orgasm take forever (women)? No? I didn’t think so. Let’s face it, talking about sexual function can be awkward and uncomfortable to many of us!

Did you know sexual dysfunction in people with diabetes is a common complication of poorly managed diabetes? Likely, it is the least often discussed complication! Let’s look at some important information to help us better understand first; what sexual dysfunction is and isn’t, why it occurs with diabetes, and then tackle how to address concerns.

Ladies first! Studies show that when women are asked about sexual function they express concern that somehow diabetes has made them less desirable or attractive and more self conscious. Women worry about sexual activity and found sexual activity to be less satisfying overall. This in turn then contributed to feeling that their relationships and level of intimacy with their partners suffered. (McCabe, Journal of Sex and Marital Therapy, 1997).

Next, Gentlemen: In a survey conducted by the National Council on aging in 2002, 79% of men aged 60 and older said maintaining an active sex life was important to them. In addition, the quality of the sexual relationship was correlated with overall marital functioning. In other words, if the sexual activity was perceived as good and satisfying - the marriage was looked upon as better and more satisfying. In another study of 1140 men of ages between 18 and 59, conducted by the National Health and Social Life Survey and reported in JAMA in 1999, those who reported having ED or erectile dysfunction were 4 times as likely to report low physical satisfaction with themselves, and 2 times as likely to report low emotional satisfaction and low general happiness.

These reports and more are evidence that our sexual health matters to our view of ourselves and our overall quality of life and feelings of well being. But does it matter enough to talk out loud about it? YES! I propose to you that a greater knowledge about what sexual dysfunction is and how it is related to diabetes will be helpful to anyone who wishes to initiate a conversation regarding prevention or treatment with their HCP, or healthcare professional.

There are three things that must happen in order for men and women to be sexually functioning human beings.

1. A person must be interested! Or, we would say sexually stimulated, either by imagery/visual or physical stimulation.
2. Sexual interest stimulates a nerve response that causes the release of a substance called Nitric Oxide that helps promote blood flow to the sexual organs of both men and women!
3. The blood flow, and subsequent engorgement of the sexual organs are inherent to sexual function.

Sexual dysfunction is a broad term and can be several things. First let me state that dysfunction is NOT being in a cranky mood or being worn out at the end of a long day! And women are different than men! Oh, you know this?! When we address sexual problems it is interesting to note that sexual problems aren’t often even called “problems” until they cause a woman distress. Men with erectile dysfunction however identified as having “ED” may be told it’s a part of aging or “all in their head.” Women with sexual problems are “just a little dry” and often sent home with a KY Jelly sample. So let me also state, sexual dysfunction is not an inevitable complication of diabetes, nor an inevitable part of aging or gender, or imagination!

What Sexual Dysfunction Is:

Women:

• Sexual arousal disorder; problems becoming aroused, often the result of not enough vaginal lubrication, decreased sensation and/or tight vaginal muscles. Leads to orgasmic disorder.
• Orgasmic disorder: recurrent or persistent delay in or lack in orgasm
• Libido disorder: lack of sex drive and interest in sex
• Infertility
• Pain or discomfort during sex or stimulation

Men:

• Erectile dysfunction: the inability to obtain and maintain an erection sufficient for penetration
• Premature ejaculation: an erection is obtained but climax and ejaculation is premature
• Libido disorder: lack of sex drive

Female sexual arousal disorder and erectile dysfunction are the types of sexual dysfunction most often related to diabetes. To begin to understand what is going on you next need a better definition of those two terms. Let’s review first other contributing factors to sexual dysfunction in both men and women.

• Alcohol use
• Tobacco use
• Urinary tract problems
• Infections (yeast and UT)
• Depression
• Anxiety
• Worry
• Medications (many for blood pressure and depression)
• Women who have entered menopause (or will soon), causing a drop in hormones that can reduce the sex drive and change the lining of the vagina causing it to become thin and painful during sex. (Women with diabetes are noted to be twice as likely to experience decreased lubrication and arousal.)

Again, Ladies first!

Sexual Arousal Disorder

Nerves respond to sexual stimulation (mental or physical) promoting release of nitric oxide. Nitric oxide in turn increases circulation or blood flow. Circulation (blood flow) is critical to the sexual experience for women, just as it is for men. Sexual stimulation (foreplay) enhances something called “venous congestion.” During venous congestion, vaginal tissues engorge with blood and fluid, a necessary part of lubrication and important preliminary stage to orgasm. Fluid literally seeps from the vaginal tissue, enhancing lubrication, promoting elongation of the vagina, engorgement of the clitoris, leading to orgasm. Orgasm is not possible without adequate lubrication.

Gentlemen, Erectile Dysfunction

Again sexual stimulation and response from nerves starts it all. Nerves send signals along the two long muscles of the penis, called corpora cavernosa. These nerves tell smooth muscle cells to relax, expand and allow circulation to increase and blood to flow in and fill the spaces. Think of the extra blood like air blown into a balloon. The nitric oxide released by nerves helps this process along. Once the tissue is filled, the nerves then send a signal to muscles to then contract and hold the blood in place. Voila, an erection! The erection ends when those muscles relax and allow the blood to flow out. When the penis is not erect, the muscles are actually tense in order to hold blood out, keeping the penis flaccid.

Sexual function problems for both men and women with diabetes occur because of the poor circulation and nerve damage, the same issues that lead to diabetes complications of all types.

1. High blood pressure and high cholesterol cause arterial damage and cholesterol plaque buildup in arteries, narrowing arteries and reducing the flow of blood. In men, arteries of the penis are exquisitely sensitive to cholesterol buildup! In women, if blood flow is impeded venous congestion and lubrication are impeded.
2. High blood glucose causes severe nerve damage, and decreased availability of nitric oxide. This leads to damage to smooth muscle relaxation (the first stage of erection), decreased lubrication and engorgement (women), and decreased sensation (women).

How prevalent is sexual dysfunction in people with diabetes? For women, evidence suggests the sexual dysfunction may be double. For men, most studies suggest ED is found three times more often over all ages.

What to do? Like other complications of diabetes (caused by high blood pressure, high cholesterol and high glucose levels) sexual dysfunction may be reduced or prevented by managing well and maintaining healthy targets.

However, if you are concerned that you already are experiencing some sexual dysfunction and you want to do something about it, start with these steps:

• See your diabetes educator for a review of your diabetes management plan and goals. Achieving healthy glucose levels may improve things quickly. They also will have more suggestions about self management of ED.
• Set up a physical with your healthcare professional to discuss your concerns.

What?! Talk out loud about this? Yes! Here’s how:

1. First picture your concerns about sexual dysfunction right along with your feet, eyes, and kidneys.
2. Fill out a health update questionnaire (there will be at least one question about sexual function) completely. Tis will give your HCP an open door.
3. During the medication review ask, “I heard that some medicines may cause problems with sex, intimacy, erection (whatever word is easiest for you), do I take any medicines like that?”
4. Mention: “I understand people with diabetes may have trouble with... could that happen to me?”
5. Tell how you heard high glucose affects blood flow and nerves and that can cause sexual problems.
6. Inquire about hormones and the changes menopause causes (women)...
7. Reveal that you read this article and think what you read may pertain to you.
8. Look for a SHIM (sexual health inventory for men). Your doctor may have these simple questionnaires available in the office.
9. Joke about those commercials on television! Then say, “Hey doc, what about that stuff, what is it really for?”

More information is available on the internet of course. Consider looking at these sites:

www.diabetes.org (the American Diabetes Association)

www.dlife.com (some show have featured sexual dysfunction for type 1 and type 2 diabetes)

www.joslin.org - for help in managing your diabetes

Once you open the door of discussion with your health care professional you will find it easier to walk in and investigate manners to prevent and treat sexual dysfunction. Your HCP is the expert here and can help you identify your contributing factors and your best management plan!