Sexual Dysfunction in Diabetes

Sexual dysfunction is a common yet often overlooked problem for both women and men with diabetes. This is unfortunate, because sexual problems can be harbingers of future cardiovascular disease (CVD) and other serious diabetic complications.

Studies of sexual dysfunction in diabetes have mainly focused on erectile dysfunction (ED) in men. Poor research methods, lack of standardized evaluation of sexual function in women, and social taboos have contributed to a historic paucity of data on sexual dysfunction in diabetic women.¹

However, known sexual problems in diabetic women include loss of libido, dyspareunia, and low sexual satisfaction, as well as decreased orgasm, lubrication, and arousal.

Hyperglycemia as well as vascular and neuropathic complications of diabetes may contribute to sexual dysfunction in women. Atherosclerosis and diabetes-related endothelial dysfunction in women can cause decreased labial engorgement and clitoral insufficiency. Exposure to chronic hyperglycemia can decrease hydration of the vaginal mucous membranes, leading to decreased lubrication and dyspareunia. Genitourinary and fungal infections related to hyperglycemia can also contribute to dyspareunia. Finally, diabetic neuropathy can affect the nerves supplying the female genitals, causing decreased response and impaired reaction to sexual stimuli.²

While the association between erectile dysfunction and CV risk is well known in men, less is known in women. However, a link between cardiometabolic risk, vascular complications of diabetes, and sexual dysfunction in women would not be surprising. A recent study used Doppler ultrasound to evaluate clitoral blood flow in 71 women. Results showed that increased clitoral vascular resistance was significantly associated with metabolic syndrome, insulin resistance, and decreased sexual arousal.³

Sexual dysfunction in men with diabetes includes orgasmic and ejaculatory problems, decreased libido, ED, and problems related to low testosterone and hypogonadism. 

Perhaps the most well-known sexual dysfunction in men with diabetes is ED. The Massachusetts Male Aging Study showed that ED is three times more common in diabetic men compared to nondiabetic men.⁴ ED also develops at an earlier age among men with diabetes. It is estimated that the rate of ED in men aged 45-49 is similar to the rate in men over age 70.²

Similar to women, metabolic, neurologic, vascular, hormonal, and psychological abnormalities all contribute to ED in diabetic men. Studies have suggested than men with higher HbA1c levels have higher rates of ED.¹ Chronic hyperglycemia and endothelial dysfunction related to diabetes can decrease levels of nitric oxide (NO) needed for penile smooth muscle relaxation, causing vasoconstriction and ED. Autonomic dysfunction related to diabetic neuropathy is probably also involved.⁵

ED has long been recognized as a sign of increased CV risk. Macrovascular disease may impair the smaller vessels of the penile circulation before larger vessels become symptomatic. For this reason, some experts have argued that ED should be regarded as the first sign of CVD.¹ Some studies have also suggested that the onset of ED may predate CV events by three to five years, providing a window of opportunity for prevention.⁶

Men with diabetes may also suffer from testosterone deficiency syndrome, which can lower libido and cause hypogonadism. Testosterone deficiency syndrome has also been linked to increased CV and all-cause mortality. ⁵

Men may also experience problems with premature, delayed, or retrograde ejaculation, likely related to diabetic neuropathy.

In both women and men with diabetes and sexual dysfunction, psychological factors like depression, anxiety, and diabetes distress may play important roles.¹

Treating sexual dysfunction in diabetic patients may require a multidisciplinary team of urologists, gynecologists, endocrinologists, and psychiatrists. While lifestyle modification and improved glycemic control may improve sexual dysfunction, they may not be enough. Because some medications contribute to sexual dysfunction, especially antihypertensives, some patients may benefit from a thorough review and adjustment (when possible) of concomitant medications. Both women and men may benefit from psychotherapy or sex therapy. 

Many pharmacotherapy options also exist. In women, vaginal estrogen may improve dryness and dyspareunia. Ospemifene, a selective estrogen receptor modulator (SERM) that is selective for vaginal tissues, may improve vaginal lubrication and dyspareunia. Systemic estrogen and flibanserin, a recently FDA-approved serotonin receptor 1A agonist and receptor 2A antagonist, can be used to treat low libido. Phentolamine may provide another option for treating problems with arousal and lubrication.²

PDE-5 inhibitors have been shown to be effective for treating ED in men with diabetes, but response may be lower than in nondiabetic men.¹ Recent studies have suggested that PDE-5 inhibitors may decrease CV and all-cause mortality by improving endothelial function.⁶ Testosterone replacement therapy may also improve sexual function, and has been associated with decreased mortality in men with T2DM.⁶

Anticholinergics, antihistamines, and α-adrenergics can be used for treating retrograde ejaculation, while ephedrine sulfate, pseudoephedrine, and imipramine may treat delayed ejaculation. Ephederine should be used with caution in men with heart disease and arrhythmias.⁵

While often a silent symptom in the clinic, sexual dysfunction is often far from silent in patients’ lives. Asking about and treating these issues may not only improve a patient’s quality of life, but address serious health problems down the road.

Take-home Points

• Sexual dysfunction is common in both women and men, and may be a first sign of macrovascular or microvascular complications.

• Women with diabetes may suffer from loss of libido, dyspareunia, and low sexual satisfaction, as well as decreased orgasm, lubrication, and arousal.

• Men with diabetes may suffer from low libido, erectile dysfunction, testosterone deficiency, hypogonadism, and problems with ejaculation.

• Asking about and treating sexual dysfunction in diabetes may address serious health problems down the road.

References:

1. Tamás V, Kempler P. Sexual dysfunction in diabetes. Handb Clin Neurol. 2014;126:223-232.

2. Phillips A, Phillips S. Recognising female sexual dysfunction as an essential aspect of effective diabetes care. Appl Nurs Res. 2015 Aug;28(3):235-238.

3. Maseroli E, et al. Cardiometabolic risk and female sexuality: focus on clitoral vascular resistance. J Sex Med. 2016 Nov;13(11):1651-1661.

4. Johannes CB, et al. Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts Male Aging Study. J Urol. 2000;163:460-463.

5. Kizilay F, et al. Diabetes and sexuality. Sex Med Rev. 2017 Jan;5(1):45-51.

6. Hackett G, et al. Coronary heart disease, diabetes, and sexuality in men. J Sex Med. 2016 Jun;13(6):887-904.