August 2018 Issue

Diabetes Management & Nutrition Guide: Treatments for Sexual Dysfunction
By Janis Roszler, LMFT, RD, LD/N, CDE, FAND
Today's Dietitian
Vol. 20, No. 8, P. 37

RDs can help clients cope with this underdiscussed and overlooked aspect of diabetes management.

At least one-half of all men and women with diabetes develop sexual complications that negatively impact their intimate relationships, self-esteem, and quality of life. RDs can offer support by listening to patients' concerns, providing information about supplements and aphrodisiacs, and encouraging them to adhere to a healthful, anti-inflammatory eating pattern such as the Mediterranean diet.

The Issues
At least 50% of men with diabetes develop erectile dysfunction (ED), with their symptoms appearing 10 to 15 years earlier than in the general population.1,2 Some men also experience decreased sexual desire, performance anxiety, retrograde ejaculation, and reduced testosterone levels.1,3-5

The presence of elevated A1c, neuropathy, or CVD can promote the development of ED.1,6 Obesity, diabetes, and metabolic diseases also are considered risk factors for sexual complications in both men and women, though studies involving women are less conclusive.

Approximately 40% to 60% of women with diabetes develop female sexual dysfunction (FSD), with postmenopausal women experiencing the highest number of symptoms, which include reduced desire, arousal/lubrication challenges, painful intercourse, and difficulty achieving orgasm. Yeast or urinary tract infections, which are more common in women with diabetes, also can limit sexual activity until itching and discomfort are resolved. Because sexual complaints tend to be underreported due to their private nature, the estimated prevalence of FSD is believed to be higher.7-10

Like men, women also can develop elevated A1c and cardiovascular and neurological issues, but these don't appear to be related to the development of FSD.7,9 Instead, obesity, metabolic syndrome, and microvascular complications are associated with FSD in women with type 2 diabetes, and issues in women with type 1 diabetes are more related to "menopausal status, depression, and marital status," according to a study by Maiorino and colleagues.9 In the study, married women with type 1 diabetes were 2.5 times more likely to experience FSD.7 Interestingly, women who take multiple insulin injections daily have a higher prevalence of FSD (27%) than do those who use insulin pumps (13%) to manage their diabetes.9

Additional Causes
Inflammation plays a role in the development of some sexual challenges. The inflammation present with visceral adiposity reduces the body's level of nitric oxide, a compound that helps muscle tissue relax so blood can flow into the pelvic area to create erections and clitoral, labial, and vaginal engorgement.2,11 Sexual complications in both men and women also can be related to unhealthful diets, physical inactivity, smoking, alcohol abuse, medication side effects (eg, antidepressants), and emotional/relationship issues.2,12

Treatments

Men
Prescription medications such as Viagra, Cialis, and Levitra work in about 60% of men with diabetes.13 Other treatment options include vacuum pumps, constriction rings, alprostadil penile injections/suppositories, penile sleeves that enable flaccid penises to participate in intercourse, and surgical implants. Implants are available as bendable rods or multipiece fluid-filled implantable types. According to the website EDCure.org, the three-piece fluid-based implantable type has a satisfaction rating among patients and partners of 92% to 98%, can't be detected, and provides a natural orgasm.

Lifestyle treatments include individual and couple's counseling, smoking cessation, reduced alcohol intake, use of depression medication with fewer sexual side effects, and behaviors that improve one's A1c level, such as a well-managed diabetes meal plan, exercise, and weight loss. The Mediterranean diet, which will be discussed shortly, is an effective option for many men with type 2 diabetes.14,15

Women
Treatments for women with diabetes include water-based vaginal lubricants, hormone and nonestrogen medications such as Osphena and Intrarosa, switching depression medications to those with fewer sexual side effects, Kegel exercises, and engaging in behaviors that increase emotional and physical wellness, such as avoiding fad diets, getting adequate sleep, limiting obligations, and participating in physical activity. Individual and couple's therapy is helpful as well.16 Women with type 2 diabetes also may enjoy increased sexual satisfaction by following a dietary pattern similar to the Mediterranean diet.17

Mediterreanean Diet
The Mediterranean diet, an anti-inflammatory regimen, can help many individuals with type 2 diabetes prevent, delay, or improve their sexual challenges. With the diet's emphasis on consuming virgin olive oil, vegetables, fruits, whole grains, nuts, fiber, fish, and moderate amounts of wine, it's associated with a lower risk and severity of ED. The diet also improves lipid and glucose metabolism and increases antioxidant defenses, and its arginine levels may raise the body's nitric oxide activity. Lycopene, found in tomatoes, contains anti-inflammatory properties that help prevent vascular dysfunction in ED, improve nitric oxide availability, and normalize aortic vasoconstriction. The diet also encourages individuals to be physically and socially active every day.15,17

Aphrodisiacs
The following is a list of popular aphrodisiacs. Their known effectiveness was compiled from selected studies and a review published by researchers at the University of California at Irvine and the Southern California Center for Sexual Health and Survivorship Medicine in Newport Beach, California.18

• Arginine: helps the body synthesize nitric oxide. The University of Hawaii School of Medicine observed that arginine significantly increased a women's sexual desire, sexual satisfaction, frequency of orgasm, and clitoral sensation19;
• Chasteberry: small amounts reduce estrogen and raise progesterone levels. Studies support its use in treating premenstrual syndrome, but there's no evidence that it helps sexual issues;
• Chocolate: increases serotonin, which can elevate mood, but research doesn't support its ability to improve sexual function;
• Damiana: comes from a Mexican shrub, and there's some evidence it may enhance sexual performance in men and women;
• Ginkgo biloba: may improve sexual dysfunction in men and women;
• Ginseng: the Korean Red variety enhances synthesis of nitric oxide, which can improve ED. It also may improve female sexual arousal;
• Honey: traditionally was used to enhance romance, but no research supports its efficacy as an aphrodisiac;
• Maca: demonstrates increased libido and improved sexual function in animal studies and also has shown promise in those areas in human studies;
• Muira puama: may increase male libido and improve ED. One small study confirmed this, but additional research is needed;
• Oysters: contain zinc, which enhances testosterone production and spermatogenesis, but don't offer any research-supported sexual benefit;
• Tribulus terrestris: comes from Asia, Africa, and Europe. An animal study showed this herb's ability to increase sperm production. A Brazilian study and a randomized, double-blinded, placebo-controlled study demonstrated its ability to improve female sexual desire;
• Wine: a small amount can stimulate sexual interest, but too much hinders performance and can prompt a drop in blood glucose; and
• Yohimbe: may promote increased blood flow to the penis, but it can cause serious health issues such as hypertension, anxiety, nausea, and flushing, and shouldn't be used.

The Dietitian's Role
RDs are uniquely positioned to help clients with diabetes meet the challenges of sexual dysfunction in the following ways:

• Some patients may choose to speak to you about their sexual challenges during a session.
• RDs can use the strong relationship between A1c and ED to motivate male patients to manage their diabetes more effectively.
• ED often develops five to 10 years before a heart attack or stroke. This information may prompt some patients to adopt more healthful lifestyle behaviors.20
• Dietitians can help men and women with type 2 diabetes prevent or improve their sexual complications by helping them incorporate Mediterranean diet recommendations into their lives.
• RDs can act as a resource about treatments for sexual complications and refer patients to mental health professionals when therapy seems appropriate. Dietitians also can direct patients to reliable educational websites such as EDCure.org, WebMD, and Mayo Clinic.
• Nutrition professionals can guide patients regarding the safe use of aphrodisiacs and supplements.
• RDs can communicate patients' concerns to other members of the health care team.

Discussing sexual topics with patients can be awkward and uncomfortable. If patients don't bring up the topic, be the one to open it up for discussion. Dietitians can mention sexual concerns in a list of other complications or just ask if patients have any issues in the bedroom. Remember, at least one-half of patients with diabetes that RDs see are struggling with some form of sexual complication. You can help!

— Janis Roszler, LMFT, RD, LD/N, CDE, FAND, was the 2008–2009 American Association of Diabetes Educators Diabetes Educator of the Year and is the author of several books, including Approaches to Behavior, Diabetes on Your OWN Terms, and Sex and Diabetes.

* Janis Roszler, LMFT, RD, LD/N, CDE, FAND, reports the following disclosures: She serves as a consultant and spokesperson for Boston Scientific and Ascensia Diabetes Care.

References
1. Maiorino MI, Besllastella G, Esposito K. Diabetes and sexual dysfunction: current perspectives. Diabetes Metab Syndr Obes. 2014;7:95-105.

2. Maiorino MI, Bellastella G, Giugliano D, Esposito K. From inflammation to sexual dysfunctions: a journey through diabetes, obesity, and metabolic syndrome [published online March 16, 2018]. J Endocrinol Invest. doi.org/10.1007/s40618-018-0872-6

3. Sexual dysfunction in males. Cleveland Clinic website. https://my.clevelandclinic.org/health/diseases/9122-sexual-dysfunction-in-males. Updated June 3, 2015. Accessed June 7, 2018.

4. Kam J, Tsang VH, Chalasani V. Retrograde ejaculation: a rare presenting symptom of type 1 diabetes mellitus. Urol Case Rep. 2017;10:9-10.

5. Grossmann M, Thomas MC, Panagiotopoulos S, et al. Low testosterone levels are common and associated with insulin resistance in men with diabetes. J Clin Endocrinol Metab. 2008;93(5):1834-1840.

6. Romeo JH, Seftel AD, Madhun ZT, Aron DC. Sexual function in men with diabetes type 2: association with glycemic control. J Urol. 2000;163(3):788-791.

7. Enzlin P, Rosen R, Wiegel M, et al. Sexual dysfunction in women with type 1 diabetes. Long term findings from the DCCT/EDIC study cohort. Diabetes Care. 2009;32(5):780-785.

8. Kouidrat Y, Pizzol D, Cosco T, et al. High prevalence of erectile dysfunction in diabetes: a systematic review and meta-analysis of 145 studies. Diabet Med. 2017;34(9):1185-1192.

9. Maiorino MI, Bellastella G, Castaldo F, Petrizzo M, Guigliano D, Esposito K. Sexual function in young women with type 1 diabetes: the METRO study. J Endocrinol Invest. 2017;40(2):169-177.

10. Rodriguez D. Is sex off-limits with a urinary tract infection? Everydayhealth.com website. https://www.everydayhealth.com/urinary-tract-infections/sex-with-a-uti-is-it-off-limits.aspx. Updated October 29, 2010. Accessed June 7, 2018.

11. Munarriz R, Kim NN, Goldstein I, Traish AM. Biology of female sexual function. Boston University School of Medicine website. http://www.bumc.bu.edu/sexualmedicine/physicianinformation/biology-of-female-sexual-function/. Accessed May 24, 2018.

12. Rice D. Diabetes and Erectile Dysfunction: A Quick 'n' Easy Handbook for the Diabetes Educator. Brighton, MI: Bella Vita Publications; 2004.

13. Francis SH, Corbin JD. PDE5 inhibitors: targeting erectile dysfunction in diabetics. Curr Opin Pharmacol. 2011;11(6):683-688.

14. Pourmand G, Alidaee MR, Rasuli S, Maleki A, Mehrsai A. Do cigarette smokers with erectile dysfunction benefit from stopping?: a prospective study. BJU Int. 2004;94(9):1310-1313.

15. Francesco DF, Tenaglia RL. Mediterranean diet and erectile dysfunction: a current perspective. Cent European J Urol. 2017;70(2):185-187.

16. Rice D, Roszler J, Farrell JB. Diabetes and sexual health. In: Weinger K, Carver CA, eds. Educating Your Patient With Diabetes. New York, NY: Humana Press; 2009:213-234.

17. Giugliano F, Maiorino MI, Di Palo C, et al. Adherence to Mediterranean diet and sexual function in women with type 2 diabetes. J Sex Med. 2010;7(5):1883-1890.

18. West E, Krychman M. Natural aphrodisiacs — a review of selected sexual enhancers. Sex Med Rev. 2015;3(4):279-288.

19. Ito TY, Polan ML, Whipple B, Trant AS. The enhancement of female sexual function with ArginMax, a nutritional supplement, among women differing in menopausal status. J Sex Marital Ther. 2006;32(5):369-378.

20. Mayo Clinic. Men's health: erectile dysfunction may indicate other health concerns [Video]. YouTube. https://www.youtube.com/watch?v=a4YpuTRQQTM&t=2s. Published March 2, 2016.