Keep Love Alive

Diabetes may affect intimacy with your partner, but there are ways to maintain a happy, healthy and satisfying relationship

Let's face it, living with diabetes can be a challenge. Depending on your individual medical condition and treatment program, diabetes can present a number of lifestyle changes. You may be taking one or more medications to help control your blood glucose levels, and checking those levels several times a day. Most likely you've had to change your diet, perhaps limiting some favorite foods, and increase your physical activity. There also may be psychological and emotional issues to deal with, including depression, stress, anger and fear. One other potential problem — a delicate one that many men, women and couples find difficult to confront — is sexual dysfunction.

Any complication associated with diabetes can potentially turn serious, although most can be overcome with proper care. That goes for sex-related problems too. "Very often people who are diagnosed with diabetes … assume that if you lose your sex life, that's a piece of the puzzle," says Janis Roszler, the co-author of Sex and Diabetes (American Diabetes Association, 2007). "That doesn't have to be so. They can get help and improve things. They can still have a very enjoyable and mutually satisfying relationship with a partner."

Of course, the aging process alone plays an antagonist's role in sexual performance. Men and women in their 60s simply don't have the same get-up-and-go that they did in their 20s. Seniors commonly experience gender-specific sexual problems, which can become mutual problems for couples who don't communicate with each other and seek help. Add diabetes to the equation, and the situation can be even trickier.

ED: Enemy No. 1 for men

For older men with diabetes, by far Enemy No. 1 is erectile dysfunction — generally known as ED. ED can stress a relationship if left unchecked. While it's more common among older men, it is not a natural effect of aging. By some estimates 50 percent to 80 percent of men with diabetes may experience ED.

"There is a direct relationship between men's blood glucose control, their A1C levels, and the possibility of developing ED," Roszler says. "Also, men need to maintain healthy blood pressure. You need to have adequate blood flow down to that area and healthy nerve communication. When the glucose levels are high in the bloodstream, it can coat the nerves and irritate the area. Think of a balloon: The only way air is going to stay in an inflated balloon is if you keep the stem pinched closed. When you loosen it, the air starts coming out. That's what's going on."

Nonetheless, Roszler says, men have several options to overcome ED.

• Oral medications. Oral prescription medications are the most popular line of defense, as indicated by the ubiquitous advertising campaigns for Viagra^®, Cialis^® and Levitra^®. Chemically known as phosphodiesterase inhibitors, those brands enhance the effects of nitric oxide, which relaxes muscles in the penis. The three products each have differences, too, as well as possible risks and side effects, particularly when combined with other medications, so consulting your physician first is imperative.

• Suppositories and injections. But oral medications don't work for all men or may have interactions with their other medications. For them, there are several viable alternatives. A similar-acting drug, alprostadil, is either inserted directly into the urethra in suppository form or injected into the penis shaft with a fine needle and syringe. Both techniques are effective, and side effects are minimal due to localization of the drug.

Dr. Phil Nguyen treats men with ED at the San Francisco office of the Boston Medical Group, which specializes in an injectable alprostadil method called intracavernous pharmacotherapy (ICP). "The needle goes about a quarter of an inch into the shaft," Nguyen explains. "It's similar to what people with diabetes use to prick their fingers to test blood sugars. It's not any more painful than that. Our patients go through a training process that teaches them where to inject it."

Each of Nguyen's patients is tested to determine his correct dosage of alprostadil. "The biggest possible side effect of ICP is a prolonged erection [of more than four hours]," he says, which indicates that a lower dosage is required.

• Vacuum devices.  Another alternative is a noninvasive treatment that involves the use of a hollow tube with a hand-powered or battery-powered pump. The penis is placed into the tube, and then the pump sucks out the air to create a vacuum that pulls blood into the penis. After achieving an adequate erection, the man slips a constriction ring around the base of his penis to maintain the erection and removes the tube. The erection typically lasts long enough for a couple to have sex, after which the ring is removed.

• Surgical implants.  A surgical treatment for ED involves implanting either an inflatable device or semi-rigid rod into the penis, allowing the man to control when and how long he has an erection. Because a penile implant is relatively expensive, it is often recommended as a last resort.

Challenges for women

Sexual health among older women with diabetes does not appear to have a strong correlation to blood glucose levels. "There are women with ideal A1C who still develop problems, such as vaginal dryness, lack of sensation or inability to have orgasms," Roszler says, suggesting that hormonal swings, stress, depression and other factors related to living with diabetes may be involved. Even so, "it's always recommended to have good blood glucose control," she adds. "For one thing, it makes you feel better. If a woman feels tired, stressed or edgy, she's not going to feel very sexual."

Besides dealing with the functional aspects of their evolving sex lives, older couples need to talk openly about what's going on — or not — when diabetes gets in the way.

Further complicating matters are the natural effects of menopause — when an aging woman's body gradually produces less estrogen and progesterone. Menopausal mood swings, fatigue and hot flashes aren't terribly conducive for sex, either. A lack of libido, stemming from diabetes-related depression or anxiety and compounded by menopause, can be addressed through counseling and medications, although possible side effects should be discussed with a health care professional.

Another reality of aging is vaginal dryness, which can result in pain and light bleeding during intercourse. Such lack of natural lubrication can be caused by a loss of estrogen during and after menopause. Hormone replacement therapy can restore estrogen production, but the treatment's safety remains the subject of debate, so consulting a physician or gynecologist beforehand is advised.

Vaginal dryness can also 
be self-remedied through the use of an estrogen-based cream or an estrogen-releasing pill or ring, available by prescription, or water-based vaginal lubricants that can be purchased over the counter.

Besides dealing with the functional aspects of their evolving sex lives, older couples need to talk openly about what's going on — or not — when diabetes gets in the way. "Let's say the man has ED," Roszler hypothesizes. "If he isn't communicating with his partner, she may feel that he is rejecting her, and that's why he isn't aroused. That brings an enormous amount of stress into the relationship that doesn't have to be there if only they were a little more open."

"Couples should appreciate that their sex life may be different as they age," Roszler says, "but it can still be quite wonderful."