Clinical Context

Diabetes is linked with more than 3-fold increased risk for erectile dysfunction in men, according to Feldman and colleagues (J Urol. 1994;151:54-61). In 2010, Lindau and colleagues reported that diabetes could potentially affect sexual function in women through vascular changes in the urogenital tissues and neuropathy-mediated changes in arousal (Diabetes Care. 2010;33:2202-2210).

This cross-sectional cohort study by Copeland and colleagues uses data from the Reproductive Risks of Incontinence Study at Kaiser 2, described by Thom and colleagues (J Urol. 2006;175:259-264), to assess whether diabetes and end-organ complications are associated with sexual activity, desire, satisfaction, and other problems.

Study Synopsis and Perspective

Sexual activity in women should be added to the list of bodily functions affected by diabetes, a new study shows.

Middle-aged women with diabetes reported lower levels of sexual desire, satisfaction, and frequency than their nondiabetic counterparts. Women with insulin-treated diabetes also reported more difficulty with lubrication, unlike women with diabetes who did not need insulin.

"These findings suggest that although many diabetic women are interested and engaged in sexual activity, diabetes is associated with a markedly decreased sexual quality of life in women either through complications of the disease itself or through use of treatments," lead author Kelli L. Copeland, BA, from the Women’s Health Clinical Research Center and the Departments of Obstetrics, Gynecology, and Reproductive Sciences, Family and Community Medicine, and Medicine, University of California, San Francisco, and colleagues write. The study appears in the August issue of Obstetrics and Gynecology.

The participants were 2270 women aged 40 to 80 years (mean age, 55 ± 9.2 years) who participated in the Reproductive Risks of Incontinence Study at Kaiser 2, a cross-sectional cohort study of risk factors for urinary tract dysfunction in middle-aged and older women recruited from Kaiser Permanente Northern California between January 2003 and January 2008. The sample included 347 women with non-insulin-treated diabetes and 139 with insulin-treated diabetes. Sexual activity and function were assessed using the Female Sexual Function Index, which has been validated and used in other large studies of women's health. The participants also were asked about the frequency of sexual activity, including masturbation, within the previous 3 months.

Sexual activity less than once a month was reported by 82 (59%) of the women with insulin-treated diabetes and 199 (57%) of the women with non-insulin-treated diabetes compared with 839 (47%) of the 1784 nondiabetic women (P = .003 for insulin-treated compared with nondiabetic patients; P < .001 for non-insulin-treated compared with nondiabetic patients).

Of the women with insulin-treated diabetes, 83 (60%) reported low sexual desire compared with 928 (52%) of the nondiabetic women (P = .04). Low sexual desire was reported by 201 (58%) of the women with non-insulin-treated diabetes (P = .05 compared with the nondiabetic women). Similarly, 38 (27%) of the women with insulin-treated diabetes and 75 (22%) of the women with non-insulin-treated diabetes complained of low sexual satisfaction compared with 304 (17%) of the nondiabetic control patients (P < .001 and P = .009, respectively).

On multivariate analysis (with adjustments made for age; race; marital or relationship status; history of sex with men, women, or both; parity; menopausal status; body mass index; hysterectomy; oophorectomy; selective serotonin reuptake inhibitor use: and estrogen use), "the odds of reporting low overall sexual satisfaction were over twofold higher in insulin-treated diabetic women and over 40% higher in non–insulin-treated diabetic women compared with nondiabetic women," the authors write. Insulin-treated diabetic women also were more likely than nondiabetic women to confirm that their physical health limited their sexual activity "extremely" or "quite a bit" (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.49 - 3.51). Diabetic women not taking insulin did not differ significantly from the women without diabetes on this measure (OR, 1.29; 95% CI, 0.92 - 1.78).

End-organ complications also were associated with diminished sexual function. Compared with diabetic women without those complications, sexual activity less than once a month was more common among women with diabetes who had heart disease (OR, 2.42; 95% CI, 1.17 - 4.98; P = .02), renal dysfunction (OR, 2.06; 95% CI, 1.16 - 3.67; P = .01), and peripheral neuropathy (OR, 1.73; 95% CI, 1.08 - 2.78; P = .02). Lower sexual desire was associated with heart disease (OR, 1.96; 95% CI, 0.99 - 3.87; P = .05) and peripheral neuropathy (OR, 1.57; 95% CI, 1.00 - 2.47; P = .05). Stroke was most strongly associated with decreased sexual satisfaction (OR, 3.32; 95% CI, 1.08 - 10.21; P = .04); however, stroke was not associated with diminished sexual activity to once or less per month, nor was stroke associated with lower sexual desire.

"This is an excellent, well-designed study," Andrea Rapkin, MD, professor of obstetrics and gynecology at the David Geffen School of Medicine at the University of California, Los Angeles, said to Medscape Medical News. "The findings are not surprising, but they are certainly important."

Dr. Rapkin was not involved in this study, but she agreed with the authors' conclusions that treatment of women with diabetes should include a sexual history and that clinicians should counsel patients that preventing end-organ complications may help preserve their sexual function.

The study was funded by grants from the National Institutes Diabetes, Digestive and Kidney Diseases (NIDDK) and the NIDDK/Office of Research on Women’s Health Specialized Center of Research. The senior author, Allison J. Huang, MD, MAS is supported by a Paul B. Beeson Career Development Award in Aging Research from the National Institute on Aging and the American Federation for Aging Research. Dr. Huang has also received research grants from Pfizer through the University of California, San Francisco, to conduct research unrelated to the study discussed in this article. The other authors and Dr. Rapkin have disclosed no relevant financial relationships.

Obstet Gynecol. 2012;120:331-340. Abstract

STUDY HIGHLIGHTS

• 2270 women 40 to 80 years old were enrolled from the Kaiser Permanente Northern California healthcare system and the Northern California Kaiser Permanente Diabetes Registry.
• Eligibility criteria were enrollment in the Kaiser healthcare plan since age 24 years and at least half of childbirths at a Kaiser facility.
• Mean age of the women was 55 years. 1006 (44.4%) were white, 443 (19.5%) were African American, 401 (17.7%) were Latina, 401 (17.7%) were Asian, and 18 (0.8%) were Native American.
• Diabetes diagnosis was determined by listings in the diabetes registry, self-report, use of diabetes glycemic control medication, or a fasting blood glucose level of 126 mg/dL or greater.
• 1784 (78.6%) of the women had no diabetes, 486 (21.4%) had diabetes, 139 (6.1%) had insulin-treated diabetes, and 347 (15.3%) had non–insulin-treated diabetes.
• Participants completed questionnaires and in-person interviews in the clinic or at home.
• Patients with diabetes completed questionnaires, physical examination, or laboratory tests to identify end-organ complications.
• Peripheral neuropathy was determined by the Michigan Neuropathy Screening Instrument scores of 2 or greater.
• Renal dysfunction of stage I or greater was defined by a glomerular filtration rate of less than 90 mL/minute/1.73 m².
• The Female Sexual Function Index questionnaire was used to assess sexual activity and frequency in the past 3 months, sexual desire and sexual satisfaction in all participants, and sexual problems in women who reported sexual activity in the past 3 months.
• Analysis was adjusted for age, race and ethnicity, relationship status, menopausal status, history of sex with men or with women, body mass index, hysterectomy and oophorectomy, selective serotonin reuptake inhibitor use, and estrogen use.
• 63.7% of the women reported some sexual activity in the past 3 months.
• Low sexual satisfaction was more common in those with insulin-treated diabetes vs those without diabetes (34.9% vs 19.3%; adjusted OR, 2.04; P = .001).
• Low sexual satisfaction was more common in women with non–insulin-treated diabetes vs those without diabetes (26.0% vs 19.3%; adjusted OR, 1.42; P = .03).
• Lubrication problems were more common in women with insulin-treated diabetes vs those without diabetes (OR, 2.37; P = .003).
• Orgasm problems were more common in women with insulin-treated diabetes vs those without diabetes (OR, 1.80; P = .05).
• Women with insulin-treated diabetes vs those without diabetes were more likely to report that their physical health limited their sexual activity (OR, 2.29).
• There were no differences in frequency of sexual activity, sexual desire, sexual arousal, or pain or discomfort with intercourse for women with insulin-treated diabetes, non–insulin-treated diabetes, or no diabetes.
• Among all women with diabetes, 60.9% had peripheral neuropathy, 39.5% had renal dysfunction, 13.4% had heart disease, and 6.4% had stroke.
• Sexual activity at less than once a month was linked with heart disease (OR, 2.42), renal dysfunction (OR, 2.06), and peripheral neuropathy (OR, 1.73).
• Low sexual desire was linked with heart disease (OR, 1.96) and peripheral neuropathy (OR, 1.57).
• Low sexual satisfaction was linked with stroke (OR, 3.32).
• End-organ complications were not linked with the level of sexual arousal, lubrication difficulty, orgasm difficulty, or pain or discomfort during intercourse.
• Women with hemoglobin A1c levels of 8.0% or higher vs those with levels of less than 6.0% were less likely to report low sexual satisfaction.
• Study limitations were cross-sectional design, use of adapted measurement tools, possible lack of generalizability to women with insulin-dependent diabetes, and self-report of some end-organ complications.

CLINICAL IMPLICATIONS

• In middle-aged and older women, insulin-treated diabetes and non–insulin-treated diabetes are associated with low sexual satisfaction and low sexual desire but are not linked with low sexual arousal or pain or discomfort during intercourse. Insulin-treated diabetes is linked with problems with lubrication.
• In women with diabetes, the end-organ complications of heart disease, renal dysfunction, and peripheral neuropathy are linked with sexual activity at less than once a month. Heart disease and peripheral neuropathy are linked with low sexual desire, and stroke is linked with low sexual satisfaction.

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