Women, Sex and Diabetes

| Feb 1, 1997

Last month Diabetes Health reported on men, sex and diabetes. In this issue, we look at some of the concerns women with diabetes may have about sex.

Sexual health is a two-sided coin. One side is physical and the other emotional. When a woman has diabetes she may have to confront pressing and emotionally draining issues on both sides of this coin. Some physical issues include vaginal dryness and recurring yeast infections. At the same time, these women may experience a lack of self-esteem, or other emotional burdens. Doctors and therapists agree that the weight of these issues should not be faced alone, and they encourage women to share their concerns and feelings.


When Deborah (this name has been changed), 27, first visited her therapist, Wendy Ullman, a licensed marriage and family therapist in San Francisco, Calif., she expressed her desire to obtain good control of her diabetes. Deborah was diagnosed with diabetes five years before their first meeting. She had gone through a stage of keeping perfect control of her blood sugar levels, but later she burned out. Now, she wanted to start keeping better control again.

"This was the first time she could really talk about what it felt like to have diabetes," says Ullman. "She said it was so wonderful to be able to share something that had been such an intimate part of her life. For the first time she didn't feel like she had to sugar-coat her problems or hide things to protect others. Once she could lay it all out, she felt better about herself."

Ullman lists some "other than the obvious" fears women with diabetes might face. The fear of rejection is one of them. A woman may keep her concerns concealed for fear that her partner will view her as being unhealthy. This could easily obstruct a healthy sexual relationship, she says. Women are so accustomed to dealing with their diabetes on their own that it can become hard to share any health problems with someone else, she adds.

"A concern women have when developing a relationship with a man is the struggle of independence versus dependence," says Daryn Stier, a psychotherapist in San Francisco. Stier suggests couples find a balance. Women may not want to depend on somebody to help them with their diabetes because it makes them feel vulnerable. As a result, this independence can cause the partner to "feel left in the dark."

On the other hand, a woman becoming completely dependent on her partner could set the stage for an unhealthy system, explains Stier. If a partner is continuously having to remind the woman of what she can and cannot do, it may cause her to become resentful. Her partner might also start feeling as if she is not listening. "This way nobody feels good inside," she says.

Relax and Let the Body Take Over

One of the most challenging issues facing women with diabetes in an intimate situation, says Ullman, is trying to relax and just let the body take over. Women with diabetes constantly have to monitor themselves and sometimes find it difficult to "just let go."

"Fluctuating blood sugar levels during strenuous sex could certainly throw a wrench in the works. The balance is trying to stay in touch with the body without being totally in control," says Ullman, who has had diabetes since childhood.

Some women feel estranged from their bodies, she explains. They feel that their bodies cannot be trusted so they tend to be distant. "It's hard to be sexually responsive when you're not in touch with your body."

Autonomic Neuropathy

Nerve damage, or autonomic neuropathy, is a common complication of diabetes. Among other problems, this condition can lead to poor bladder control and poor vaginal lubrication. These problems, resulting in inconvenience and discomfort, can have an effect on a woman's libido.

When the nerves to the bladder become damaged women may have poor bladder control and may be unable to empty their bladder completely. Women suffering from the problems associated with a neurogenic bladder, such as a bladder infection, are advised to urinate before intercourse and within 30 minutes after.

The American Diabetes Association suggests people suffering from inconsistent urine release follow a planned bladder-emptying program. This requires urinating at specified times. The Association suggests trying to urinate every hour or two, instead of waiting until the bladder feels full.

Don't Let Dryness Slow You Down

In their book, The Diabetic's Book: All Your Questions Answered, June Biermann, who has type I diabetes, and Barbara Toohey, explain, "neuropathy É may involve the nerve fibers that stimulate the genitalia so that arousal may not occur, making intercourse painful because lubrication fluids are not released."

If this situation occurs, water-soluble lubricants like K-Y Lubricating Jelly by Johnson & Johnson can be helpful. Cindy Onufer, RN, MA, CDE, notes that Astroglide, a water-soluble lubricant by Biofilm Inc., has been especially helpful for many of her patients. Do not use Vaseline or other oil-based products, because they result in condom damage and can foster bacterial growth, leading to infection.

Wary of Hormone Therapy?

Poor vaginal lubrication can effect women with type I or type II diabetes. In many cases the cause is low hormone levels. People suffering from poor lubrication should not diagnose it as a hormone problem themselves. A doctor needs to determine the cause of the problem in order to prescribe the best medicine.

To counter low hormone levels, a doctor might recommend estrogen, also called hormone therapy. Estrogen can be delivered to the body by taking an oral medication, wearing a patch or applying a vaginal cream.

"In the old days, women with diabetes were told not to go on hormone therapy because it was thought that it had an effect on sugar levels. Now those issues are a thing of the past. Women should not be afraid of hormone therapy. New, low doses are on the market that have no negative effect on women with diabetes," says Eileen Walko, MD, at Kaiser Permanente of Hawaii.

Recurring Yeast Infections

"Women with diabetes tend to suffer more from vaginal yeast infections than those without diabetes," says Walko. This is because yeast and bacteria thrive in moist, sweet, warm places. Women with diabetes tend to have more sugar in their urine causing yeast to grow out of control. Fortunately, there are some over-the-counter remedies, such as Monistat 7 and Gynolotramin, that are effective in combating these infections and safe for people with diabetes.

When a woman is in poor control of her diabetes, yeast infections might occur more frequently. In these cases, doctors can prescribe a fairly new oral medication, Diflucan. "Diflucan is reserved for women with recurring yeast infections. It's a one or two time cure. It's more expensive," says Walko, who was diagnosed with type I diabetes after seeing a doctor about recurring yeast infections when she was 14 years old.

Once women with type II diabetes enter menopause they are more susceptible to yeast infections and vaginitis, according to the ADA's Complete Guide to Diabetes. When the menopause process begins, estrogen production slows down, decreasing the amount of nourishment supporting the vaginal lining. This makes it easier for yeast and bacteria to grow.

The ADA lists three precautions for women to take during menopause to help prevent vaginal infections: keep blood glucose levels under control, bathe regularly to keep fecal bacteria from entering the vagina, and consider hormone replacement therapy. Some doctors also recommend eating low-fat yogurt with active cultures on a daily basis to help battle yeast in the digestive tract.

Contraception Misconception

"There is new research that says diabetic women can, in fact, use low-dose estrogen birth control pills. However, if a woman has been told by her doctor that these pills would complicate any existing conditions, then she should think about using other forms of birth control," says Walko.

High blood pressure is a possible side effect of the birth control pill. If this happens to a woman with diabetes, the chance of kidney and eye disease worsening could increase.

Orgasm or Low Blood Sugar?

Dr. Lois Jovanovic-Peterson, in her book Diabetic Woman, suggests a woman with type I diabetes should be aware of hypoglycemic episodes during and after sex. "She should adjust her insulin downward in anticipation of the evening, or if the evening happens to be on the spur of the moment, she should compensate by eating something afterward," she says.

"Some women put out an adrenaline response when they are having sexual intercourse. This is similar to low blood sugar-a loss of control, sweating and an erratic heartbeat," says Walko. Some women question if they are experiencing a hypoglycemic episode or an orgasm. She suggests women check their blood sugar levels before having sex to clear up any misinterpretations.

You're Not Alone

Research on women with diabetes and sexuality remains sparse. Some professionals believe this is because these women do not suffer greatly from sexual complications, while others feel it is because patients and health care providers avoid discussing the topic. Pat Schreiner-Engel, PhD, at Mt. Sinai Hospital in New York, is exploring this uncharted territory. A study she conducted indicates that women with premenopausal type I diabetes do not have higher rates of sexual problems than women of the same age who do not have the disease. The study, whose subjects were 46-year-old women, found that women with type II diabetes were more likely to have more sexual difficulties than others in their age group without type II diabetes.

Women, with type I or type II diabetes should not face sexual difficulties alone. They should be aware of the possible sexual complications, emotional and physical. Doctors and psychotherapists can help women avoid complications and keep them up-to-date on new products that can help make an intimate experience more enjoyable. Sex is a part of human nature and belongs in a healthy life. Take advantage of the possibilities. But, Cindy Onufer, RN, MA, CDE, stresses, "whether or not you have diabetes, safe-sex precautions are paramount for everyone."

- - - - -

Discussing a sexual problem with a doctor could help expel concerns or fears a woman with diabetes might have. A doctor will probably ask a variety of questions. The American Diabetes Association lists some questions that may seem embarrassing but could help assess whether the problems are physical or emotional.

  • Have you experienced a loss of interest in sex?
  • Have you experienced vaginal dryness?
  • Do you experience tightness during or after sex?
  • Do you have any pain or discomfort during or after sex?

A therapist will probably have a different way of addressing one's sex life than a medical doctor, says Wendy Ullman, a therapist in San Francisco. A medical doctor looks for medical conditions, while a therapist will try to make sex a discussible subject. "I probably wouldn't ask a direct question," she says.

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