Diabetes and Sexual Dysfunction -Dr Shahjada Selim

1. Diabetes and
Sexual Dysfunction
Dr Shahjada Selim
Associate Professor
Department of Endocrinology, BSMMU
Visiting Professor in Endocrinology, Texila American University, USA
Website: shahjadaselim.com

2. Diabetes mellitus
Diabetes mellitus is one of the most common chronic diseases in
all countries of the world and it has been declared as global
pandemic in 2012.

3. Estimations and projections of the number of people (20-79 years)
with diabetes in different editions (millions)[1]
1. IDF Diabetes Atlas 9e 2019

4. Diabetes & Sexual Dysfunction
• DM has been associated with sexual dysfunction both in men and in
women.
• DM is an established risk factor for sexual dysfunction in men; in the
Massachusetts Male Aging Study a threefold increased risk of erectile
dysfunction (ED) was documented in men with DM than men without
diabetes [1].
• Among women, the evidence regarding the association between
diabetes and sexual dysfunction have been reported at a higher
prevalence of female sexual dysfunction (FSD) in women with diabetes
as compared with women without diabetes [2,3].
1. Feldman HA et al. J Urol. 1994;151(1):54–61.
2. Penson DFetal..Diabetes Care.2003;26(4):1093–1099.
3. Lu CC et al. J Sex Med. 2009;6(6):1719–1728.

5. Erectile dysfunction (ED)
ED is defined as the persistent inability to achieve or maintain
penile erection for successful sexual intercourse, causing
decreased quality of life in men. ED is a common sexual disorder
that increases with age [1].
The natural history of ED in people with diabetes is normally
gradual and does not occur overnight. Both vascular and
neurological mechanisms are most commonly involved in people
with diabetes.
1. Feldman HA et al. J Urol. 1994;151(1):54–61.
Diabetes & Sexual Dysfunction in Men

6. 1. Castela, Â et al. Nat Rev Urol 13, 266–274
Diabetes, endothelial dysfunction and
ED

7. ED in DM
People with DM may present with several clinical conditions, including
[1]:
• Smoking
• Hypertension
• Hyperlipidemia
• Metabolic syndrome
• Depression
• Lower urinary tract
symptoms
• Poor health state.
Moreover, ED is a marker of significantly increased risk of CVD, CHD, stroke,
and all-cause mortality.
1. Esposito K et al. Diabetes Care.2005;28(5):1201–1203.

8. 12. Selvin E et al. Am J Med. 2007
Feb;120(2):151-7.
14. Walsh TJ et al. Int J Impot Res.
2014 May-Jun;26(3):112-5
How common is Erectile Dysfunction in men with diabetes?

9. ED in DM in Bangladesh
1. Selim et al. J Diabetes Metab 2016, 7:8(Suppl) http://dx.doi.org/10.4172/2155-6156.C1.052
2. Mahbub MI et al. Mymensingh Med J 2019 Jan; 28 (1): 137-143
The frequency of ED was increased with age from 35.5% in men aged 28-
39 years to 100% in those aged 60 years and above (p<0.001) (n=503). [2].
The overall frequency of ED was 53.1%. The frequency of ED
increased with age, ED frequency was 58.4% in those aged 60–69 years
being 8 times more likely than those aged 30–39 years (P < 0.0001). The
percentage of patients with mild ED decreased from 5.1% among those
aged 20–39 years (n=813) [1].

10. Testosterone Deficiency (TD) & ED
Testosterone regulates nearly every component of erectile function,
from pelvic ganglions to smooth muscle, and to the endothelial cells of
the corpora cavernosa.
It also modulates the timing of the erectile process, which occurs as a
function of sexual desire, coordinating penile erection with sex.
It is still unclear what level of testosterone is needed for good erectile
function; however, evidence derived from clinical and molecular
studies supports the use of testosterone replacement in hypogonadal
patients with ED, although the benefit–risk ratio is uncertain in
advanced age [1,2].
1. Shabsigh R et al. Int J Clin Pract. 2006;60(9): 1087–1092.
2. Isidori AM et al. Eur Urol. 2014;65(1):99–112.

11. Insulin resistance and visceral adiposity
Insulin resistance and visceral adiposity, which are both
distinctive clinical traits of T2DM, are associated with a
proinflammatory state that results in the decreased availability
and activity of NO, leading to ED in overweight and obese
diabetic men

12. ED in DM- Diagnosis
ED can be easily detected by having male patients complete
standardized questionnaires investigating their sexual function.
One of the most practical questionnaires that is administered is
the International Index of Erectile Function (IIEF)-5, which
consists of items 5, and 7 from the full-scale IIEF-15; a sum score
of 21 or less indicates the presence of ED.

13. Treatment of ED

14. Glycemic control and lifestyle modifications
Glycemic control
• Tight glycemic control - Maintain an HbA1c concentra-
tion (at around 6.5% HbA1c)
Lifestyle changes
• Increased physical activity, maintain optimum body wt
• A low calorie diet (less carb, less animal sat fats)
• Reduced salt

15. Female Sexual Dysfunction (FSD)
FSD is a complex condition that affects women of all ages and races.
It is characterized by disturbances in the psychophysiological changes
associated with the sexual response cycle in women, and it includes
disorders of sexual desire, arousal, orgasm, and pain.
In 2010, the Third International Consensus of Sexual Medicine
accepted revised definitions of FSD, emphasizing a model based on
a circular pattern of the sexual female response, in which different
phases of sexual function can overlap [1].
1. Basson R et al. J Urol. 2000;163(3):888–893.
Diabetes & Sexual Dysfunction in Women

16. FSD and diabetes: risk factors and association
 FSD have been described in women with diabetes since the
early 1980s. Sexual disorders reported in women with diabetes
include the reduction or loss of sexual interest or desire, arousal
or lubrication difficulties, dyspareunia, and loss of the ability to
reach orgasm. FSD has been associated with both type and type
2 diabetes.
 A recent meta-analysis that included 26 studies, 3,168 women
with diabetes, and 2,823 controls showed that FSD is more
frequent, and is associated with a lower Female Sexual Function
Index (FSFI) score in diabetic women than in controls. In
particular, the risk for FSD was 2.27 (95% CI: 1.23–4.16) and
2.49 (95% CI: 1.55–3.99) in type 1 and type 2 diabetic women,
respectively.
1. Tyrer G et al. Diabetologia. 1983;24(3):166–171

17. Sexual Dysfunction
overlay of
pathogenesis in
females with DM
1. Ravinder K et al. Pharm
Tech Res Manag; 6(2): Nov.
2018

18. 1. Shivananda MJ etal. Curr Opin Psychiatry. 2016;29:331–5.
23. Maiorino MI et al. Diabetes Metab Syndr Obes. 2014;7:95–105.

19. FSD and diabetes: risk factors and association
• In conclusion, psychological concerns may play a significant role in
the development of FSD in both type 1 and type 2 diabetes. This is in
line with the complex nature of female sexuality, which is largely
dependent on psychological and cultural factors, even more so than
male sexuality.
1. Veronelli A et al. J Sex Med. 2009;6(6):1561–1568.

20. Tips for Addressing Sexual Functioning With Diabetic Women [1]
Enzlin p et al. Diabetes Spectrum; 16(4):256-259

21. Sexual problem Treatment
Reduced vaginal
lubrication
• Education regarding need for adequate stimulation prior to penetration
• Water-based vaginal lubricants
• Hormone replacement therapy
• Arousal enhancement strategies
Genital infections • Treatment of genital infections
• Genital hygiene education
Vulvodynia/dyspareunia • Investigation and treatment of underlying condition
• Lubricants
• Reduced focus on penetrative sex
Anorgasmia
(inability to orgasm)
• Penetrative/non-penetrating vibrating sex aids
• Clitoral therapy devices
• Psychosexual support
Reduced libido • Review and treat any concurrent depressive illness
• Psychosexual support for any self- image issues
• DHEA supplementation
• Estrogen/androgen replacement
• Flibanserin (serotonin 1A receptor agonist and a serotonin 2A receptor antagonist)
• PDE-5 inhibitors
Treatment options for sexual problems in women with diabetes [1,2,3]
1.Miner M et al. J Sex Med. 2012;9:641–51.
2.Mills L et al. Journal of Diabetes Nursing. 2015;19:272–5.
3. Tamás Vetal. Handb ClinNeurol. 2014;126:223–32.

22. Summary of the available therapies for FSD
Modification of risk factors (weight control, healthy diet, regular
exercise)
Addressing psychological issues
Cognitive behavioral psychotherapy for desire disorders or
vaginismus
Clitoral therapy device for arousal or orgasm disorders
Treatment of depression, if present
Hormonal replacement therapy in postmenopausal women

23. Treatment of FSD
• Sexual dysfunction in women DM may benefit from both the resolution of
psychological issues and the treatment of depression with specific medical
therapy. Moreover, achieving adequate glycemic control is of paramount
importance for diabetic women, in order to help reduce the risk of genitourinary
infections and avoid complications.
• At present, there are no FDA- approved transdermal or oral androgen
therapies for FSD, whereas hormonal replacement therapy is approved for
postmenopausal women. Acting on NO-mediated smooth muscle relaxation to
increase vasodilatation, PDE5 inhibitors might theoretically improve vaginal
lubrication and vulvar engorgement.
1. Uckert S et al. J Sex Med. 2007;4(6):1604–1609

24. Treatment of FSD
• In contrast, few successes have been reported for the use of these agents
in the treatment of sexual arousal problems in women; this is likely due to
the inconsistencies observed between the physiological and psychological
fac- tors on sexual response,133 or the low PDE5 levels noted in the
female reproductive system [1].
• Further research is needed in order to investigate the effects of
diabetes on female sexual function, and hence to provide effective
therapeutic opportunities for these women.
1. Uckert S et al. J Sex Med. 2007;4(6):1604–1609

25. In Conclusion
Diabetes mellitus is a growing public health concern, leading to
cardiovascular, psychological, and sexual dysfunctions. Diabetes
is a well-known cause of ED, with prevalence rates approaching
50% in both type 1 and type 2 diabetes.
The determinants of ED in diabetic men include glycemic control
and most of the principal cardiovascular risk factors, such as
hypertension, hyperlipidemia, overweight and obesity, metabolic
syndrome, smoking, and sedentary lifestyles.

26. In Conclusion
Moreover, ED is an independent risk factor for the new onset of
CVD, and it is an important predictor of the development of major
cardiovascular events in diabetic patients with known CAD.
The debate as to whether FSD should be classified as a
dysfunction similar to ED or whether it should be considered a
pathologic condition at all is not ended.
Although diabetic women suffer from the same neurovascular
complications that contribute to the pathogenesis of ED in men,
results of sexual functioning of diabetic women are less conclusive.

27. In Conclusion
However, a high prevalence of FSD has been described in both
type 1 and type 2 diabetic women as compared with non-
diabetic women, with most studies reporting psychosocial
issues as a main determinant of FSD.
Although ED in men has been recognized as a powerful
predictor of major cardiovascular events, it is still not clear
whether FSD may be indicated as a risk factor for CVD.

28. In Conclusion
 The promotion of a healthful lifestyle, including the adoption of a
healthy diet and engaging in exercise, for the prevention and
treatment of cardiovascular risk factors among individuals of all
ages yields great benefits and reduces the burden of chronic
diseases.
 Extending beyond the specific effects on sexual dysfunction in
men and women, the adoption of these measures promotes a
healthier life and increased well-being, which in turn, may help to
reduce the burden of sexual dysfunction.

29. In Conclusion
 Regarding the high prevalence of sexual dysfunction in women with
type 2 diabetes, it is essential for health policy-makers to take
effective control as well as treatment measures, including periodic
sexual care, for women with type 2 diabetes.