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This study aimed to investigate the prevalence and risk factors associated with sexual dysfunction in a well-characterized cohort of women with type 1 diabetes. The study was conducted in women enrolled in the long-term Epidemiology of Diabetes Interventions and Complications EDIC study, a North American study of men and women with type 1 diabetes.
At year 10 of the EDIC study, female participants were invited to complete a validated self-report measure of sexual function, standardized history and physical examinations, laboratory testing, and mood assessment. FSD is common in women with type 1 diabetes and affects all aspects of sexual function and satisfaction. Depression is the major predictor of sexual dysfunction in women with type 1 diabetes. These findings suggest that women with type 1 diabetes should be routinely queried about the presence of sexual dysfunction and possible co-association with depression.
Diabetes has long been considered a major cause of impaired sexual function. Both men with type 1 and type 2 diabetes have been shown to have substantially increased risk of erectile dysfunction ED 1 — 5. Beyond the effects of comorbidities, such as older age, use of antihypertensive medication, high BMI, and smoking, the severity and duration of diabetes and its vascular and neurological complications, which cause abnormalities in the endothelium or nitric oxide—related mechanisms in the corpora cavernosa, have been strongly linked with the development of sexual dysfunction in men 145.
Women with diabetes have similar rates of cardiovascular and neurological complications, and therefore similar rates of sexual dysfunction might be anticipated. Sexual functioning of women with diabetes, however, has received far less attention in research, and are less conclusive than those of studies in men 6. In general, studies of sexual dysfunction in women have lagged behind those in men, likely due to several factors, including a lack of standardized definitions of sexual dysfunction in women, absence of well-validated scales, and societal taboos regarding female sexuality 78.
studies of sexual dysfunction in women with diabetes are small in and have ificant methodological drawbacks, including small sample sizes and lack of adequate characterization of diabetes, particularly with regard to glycemic control, neurovascular complications, psychological adjustment to diabetes, and presence or absence of comorbid depression 6. Nevertheless, preliminary reports have noted a high prevalence of sexual dysfunction in women with diabetes.
In particular, a mixed pattern of sexual symptoms has been found, including loss of sexual interest or desire, arousal or lubrication difficulties, painful intercourse dyspareuniaand loss of the ability to reach orgasm 6.
In a recent study, women with type 1 diabetes had increased rates of sexual dysfunction compared with age-matched control subjects 9. In contrast to studies in men, no association was found between sexual dysfunction and cardiovascular, metabolic i. Another study further revealed that sexual dysfunction in women with diabetes is related more directly to psychological factors, i.
This latter finding is consistent with other studies showing depression to be a major risk and comorbid factor of FSD 3. Accordingly, this study aimed to evaluate the prevalence, type, risk factors, and predictors of FSD in a prospective observational study examining the risk factors associated with long-term complications of type 1 diabetes in women The original cohort of the DCCT consisted of 1, men and women 13—39 years of age at study entry.
They entered the DCCT trial between and and were studied for an average of 6. In total, patients were randomly ased to receive conventional diabetes treatment, and were randomized to receive intensive diabetes treatment. Inthe DCCT was discontinued due to statistical evidence of a powerful salutary effect of intensive treatment on long-term complications At study close-out, DCCT subjects were encouraged to use intensive therapy and invited to the EDIC study, a multicenter longitudinal observational study.
At EDIC year 10, 1, patients men and women were invited to complete self-report measures of sexual dysfunction and urological complications i. A total of On the annual anniversary of enrolling in the DCCT, each EDIC subject underwent a standardized annual history and physical examination, including a detailed evaluation of overall health, diabetes management, occurrence of diabetes complications, development of new disease, and medications used.
Annual evaluations also include resting electrocardiograms, Doppler ultrasound measurements of ankle and arm blood pressure ratios, and arm blood pressure. Lipid profiles and 4-h urine collections for measurement of albumin excretion rate and creatinine clearance are obtained on alternate years using the same methods as in the DCCT The FSFI is a widely used, multidimensional, well-validated, self-report measure that assesses sexual function across six domains, including sexual desire, arousal, lubrication, orgasm, satisfaction, and pain 151617 From each of the domains of sexual desire, arousal, lubrication, orgasm, and pain, one item was included together with two items from the sexual satisfaction domain.
The items are 5-point Likert-type items, with higher scores reflecting worse sexual functioning. The FSFI-R total score is the sum of all the items representing each domain of sexual functioning added with the mean score of the two items assessing satisfaction. The psychometric properties of the FSFI-R were evaluated using an independent sample of women with and women without sexual dysfunction selected from validation studies 1617 For continuous measures, a nonparametric Kruskal-Wallis test was used.
Analyses were performed using SAS version 8. In addition, the sample who completed the survey did not differ on DCCT variables at baseline compared with the women who did not participate in the study. In total, women This report thus describes obtained from eligible participants: in the conventional and in the intensive treatment groups.
The mean age of the participating women was However, at the year 10 examination in the EDIC study, women randomized to intensive treatment were less likely to have retinopathy, nephropathy, and peripheral neuropathy than those randomized to conventional treatment. For all sexual domains, study participants without FSD scored higher i. Percentages are based on total sample size minus the of missing values. Univariate analyses were conducted to examine which variables predicted the presence or absence of sexual dysfunction in women with type 1 diabetes Table 2.
When controlling for the effects of other variables, depression status depressed vs. Women with type 1 diabetes in our sample who showed s of depression were 2. Married women with type 1 diabetes were 2. In addition to the relationship with each of the major predictor variables, the differences between the treatment groups in specific domains of sexual function were both univariately and multivariately analyzed.
In the univariate analyses, associations were found between menopausal status, marital status, the composite diabetes complications variable, the log of A1C at DCCT baseline, and depression and the individual sexual domains. The multivariate per individual sexual domain are summarized. The complex composite variable was statistically ificant with respect to FSD in the lubrication for three vs. Being married was the only ificant risk factor for FSD in the desire domain for married vs.
Menopause was an important risk factor for FSD in the lubrication domain for menopausal vs. These findings are based on the largest well-characterized prospective cohort of women with type 1 diabetes in which sexual function has been evaluated. The fact that in studies different questionnaires were used and that participating women were even younger in age might partially for the differences observed. Although rates of sexual dysfunction in women are not dissimilar to those in men, the pattern of specific effects of diabetes on men and women is markedly different.
While ED affects men both with type 1 and with type 2 diabetes, the most prevalent sexual dysfunction, lubrication and sexual arousal difficulties, were not the sole or the most prevalent problem in women. Moreover, ED is strongly correlated with A1C and the cardiovascular and neuropathic complications of diabetes 34 Again, in contrast, our study reveals in a multivariate analysis that FSD in women with type 1 diabetes is most strongly and consistently correlated with depression and marital status.
The lack of association between any measurement of A1C and FSD in this study suggests that compared with men, the sexual response in women with diabetes is more likely to be affected by the psychosocial aspects e. Similar regarding the association between depression and FSD were observed in a study of younger women with type 1 diabetes This finding is also consistent with of other studies of sexually dysfunctional women, in which associations have been observed between FSD and depression The current study thus provides further evidence for the hypothesis that in diabetic women, sexual dysfunction is more strongly related to psychosocial aspects rather than the typical pattern of cardiovascular- and metabolic-related risk factors observed in studies of men with diabetes 34 Several explanations can be offered to for the different pattern of effects in men and women.
It is conceivable, for example, that these differences in sex risk factor profiles are due to differences in the underlying physiological mechanisms e. As early asSchreiner-Engle 23 hypothesized that diabetes-related vasculopathy or neuropathy might be less readily perceived by women and that women with diabetes might not be aware of a relative decreased lubrication response and therefore not likely to report it, in contrast to men who readily experience and report ED.
Because of the multidimensional etiology of FSD in women with diabetes, it will be necessary for future research to use a more comprehensive assessment of sexual function, including a combination of both subjective i. In this respect, we should note that Wincze et al.
Further studies in this area would be valuable to test alternative hypotheses and to determine whether treating a mood disorder in women with type 1 diabetes contributes to improved sexual function independent of glycemic control. Finally, some limitations of the study need to be acknowledged. Although this study is based on a prospective, longitudinal, observational study of treatment effects in patients with type 1 diabetes, the analyses presented are from a cross-sectional analysis of data obtained at year follow-up. Future studies in this field should, therefore, use a true longitudinal de to more directly test sequence effects and order of changes in sexual function and to further elucidate the differences observed between the sexes.
Also, since the population of the EDIC-study is in certain respects limited in its diversity age, race, and diabetes typethe of this study only apply to Caucasian, relatively young women with type 1 diabetes. Future research should attempt to include more diverse samples in order to examine the risk and risk factor of FSD in other groups.
However, by restricting our analyses to this group of women, we are able to ascertain specific effects on each of the sexual function domains in relation to specific risk factors or predictors. A final limitation is that no nondiabetic control women were included in the study, and we therefore relied on norms from clinical studies to interpret the prevalence of the sexual dysfunctions observed.
However, this is not a serious limitation in view of the large body of published data on sexual dysfunction in the general population in both men and women. In conclusion, the of this study provide further evidence that women with type 1 diabetes are at risk for several sexual dysfunctions. In contrast to findings in men, our showed that in women with type 1 diabetes, depression and marital status are the main predictors of FSD, whereas glycemic control and complications were not associated with FSD. Further studies are needed to elucidate the mechanisms underlying these differences. Considering that FSD can have an important negative effect on quality of life and partner relationships, the sexual difficulties of women with diabetes warrant more attention in both research and practice.
Similar to the annual evaluation of diabetes complications, women with type 1 diabetes should also be regularly queried about the presence of depressive symptoms, sexual function, and sexual satisfaction. The costs of publication of this article were defrayed in part by the payment of charges. Section solely to indicate this fact. National Center for Biotechnology InformationU.
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