Objective: This study was designed to assess sexual dysfunction in women suffering from type 2 diabetes mellitus. Subjects and Methods: Forty-five type 2 diabetic, non-menopausal married women, aged 20-55 years, who were referred to Shahid Labbafinejad Clinics from March 2008 to June 2009 were included in this study. They were compared to 91 non-diabetic volunteers. Sexual function was evaluated by the sexual function questionnaire. Genitourinary examination was performed in all subjects. Blood sample tests were requested for fasting blood sugar, hemoglobin A1c, 2-hour postprandial glucose and lipid profile measurements. Ophthalmologic and neurologic examinations (checking deep tendon reflexes) were done for cases. Results: The mean age of cases and controls was 42.17± 5.91 and 34.96 ± 8.30 years, respectively (p < 0.001). The prevalence of a high probability of female sexual dysfunction in 6 domains including desire, arousal sensation, arousal lubrication, orgasm, pain and enjoyment was 71.1, 84.4, 55.6, 71.1, 8.9 and 66.7% in the diabetes mellitus women and 56.6, 67.0, 59.3, 57.1, 25.3 and 53.8% in the non-diabetic volunteers, respectively. Differences were statistically significant in the 3 domains of desire, arousal sensation and pain (p < 0.05). Deep tendon reflexes were normal in all and 12.5% showed diabetic retinopathy. Conclusions: Sexual dysfunction in cases as well as in controls was high; however, further studies with a higher number of patients are needed to confirm the results.

Diabetes mellitus is a common disease that may impair sexual activity in men and women. According to the American Diabetes Association, 20.8 million (7%) of Americans have been diagnosed with diabetes mellitus [1]. In men, diabetes mellitus has long been recognized as a major risk factor for impaired sexual function as 20 to >70% of diabetes mellitus men suffer from sexual dysfunction that include primary erectile dysfunction, pre-ejaculation, orgasm and desire [2,3,4]. Female sexual dysfunction is a highly prevalent health problem affecting 25-63% of women [5,6,7]; the prevalence of female sexual dysfunction and the associated risk factors are less clear than in men [8]. Estimates of the prevalence of female sexual dysfunction vary greatly depending on the definition, the assessment tool used and population demographics (education, marital status, age and race) [9].

In this study, we evaluated female sexual dysfunction in type 2 diabetic mellitus non-menopausal women in comparison with non-diabetic volunteers with the same age range.

Our study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences.

Forty-five type 2 diabetic mellitus, non-menopausal married women, aged 20-55 years, were included in this study from March 2008 to June 2009 at the Shahid Labbafinejad Medical Center. The control group included 91 non-diabetic, married volunteers with the same age range. An internal medicine specialist and endocrinologist (R.G.K.) confirmed the type of diabetes mellitus. Exclusion criteria were: married women who lived apart from their spouses; history of major diseases such as neoplasm, heart failure or end organ damage such as chronic renal failure; history of sexual abuse, major depression, or history of regular use of antidepressants or anxiolytics, as well as signs of severe organ prolapse such as uterine prolapse, cystocele stage ≥3 or signs of perineal iatrogenic severe scars (due to previous surgeries) which prohibited effective entrance. At the first visit, patients and controls got a code number. A general physician filled in the demographic questionnaire for all participants. Both groups filled in the sexual function questionnaire (SFQ) by themselves with or without the aid of an assistant (Appendix).

The SFQ contained 31 questions evaluating sexual function in 6 domains: desire, arousal sensation, arousal lubrication, orgasm, pain, and enjoyment. All subjects obtained a score for each domain. According to their scores, women were categorized into three groups: high probability for sexual dysfunction, borderline probability for normal sexual function, and high probability for normal sexual function (Appendix).

Venous blood samples were withdrawn for fasting blood sugar, glycosylated hemoglobin A1c, 2-hour postprandial glucose test and lipid profile (cholesterol, triglyceride, low-density lipoprotein, high-density lipoprotein) measurements in both groups. Genitourinary examination was performed in mid-cycle at lithotomy position by an experienced female urologist (F.S.), and the patient was evaluated for evidence of pelvic organ prolapse based on pelvic organ prolapse quantification [10] or any severe perineal iatrogenic scars. To evaluate the effect of diabetes on sensory motor response, a monofilament test and deep tendon reflexes were carried out in all diabetic cases. All diabetic patients were referred to an experienced ophthalmologist to test for signs of retinopathy.

Data were evaluated using SPSS 16 software. Data are reported as the mean and standard deviation for continuous variables and frequency and relative frequency for categorical variables. Groups were compared using the t and χ2 test; for multivariate analysis, ANCOVA was used. The statistically significant level was set at p < 0.05.

The age range of both the case and the control group (20-55 years) was 42.1 ± 5.9 and 34.9 ± 8.3 years, respectively, and the difference was statistically significant (p < 0.001).

The characteristics of the case and control groups are shown in table 1. The mean body mass index of diabetics and controls was 29.2 ± 5.9 and 26.4 ± 4.2, respectively (p < 0.001). The mean duration of diabetes mellitus in the case group was 6.35 ± 5.41 years.

Table 1

Characteristics of cases and controls

Characteristics of cases and controls
Characteristics of cases and controls

Only 2 (4.4%) patients had reduced results in the monofilament test. Deep tendon reflex tests were normal in all cases. The characteristics of diabetes mellitus patients are shown in table 2.

Table 2

Characteristics of diabetes mellitus patients

Characteristics of diabetes mellitus patients
Characteristics of diabetes mellitus patients

Thirty-four (75.6%) and 55 (61.1%) subjects of the control group had a history of genitourinary and colorectal surgery. Twenty-four (53.3%) cases showed results of ophthalmologic examination; 3 (12.5%) had diabetic retinopathy.

The mean serum level of fasting blood sugar for cases and controls was 162.83 versus 89.11 mg/dl, and for triglyceride, 176.44 and 126.69 mg/dl (table 3), respectively. There was a statistically significant difference between cases and controls.

Table 3

Comparison of blood sample parameters between cases and controls

Comparison of blood sample parameters between cases and controls
Comparison of blood sample parameters between cases and controls

Of the 45 cases and 91 controls, 32 (71%) and 51 (56%) suffered from dysfunction in sexual desire, respectively (p = 0.009; table 4; Appendix). Thirty-eight (84%) cases and 61 (67%) controls suffered from arousal sensation problems; the difference was statistically significant (p = 0.027). Also, 4 (8.9%) cases and 23 (25.3%) controls had pain disorders. There was no significant relationship between sexual function, body mass index, job, smoking, and glycemic control.

Table 4

Comparison of the 6 domains of female sexual dysfunction in cases and controls based on the SFQ

Comparison of the 6 domains of female sexual dysfunction in cases and controls based on the SFQ
Comparison of the 6 domains of female sexual dysfunction in cases and controls based on the SFQ

In our study, the domains of desire and arousal sensation were more adversely affected in the cases than in the control group (p < 0.05), as previously reported [11,12]. The World Health Organization recognized the importance of human sexuality as part of an individual's health and well being in 1974 [13]. Several factors contribute to sexual activity in women such as sexual education, economic status and relationship with partner, family issues, depression and others. The high rate of desire and arousal sensation dysfunction in our study may be related to the higher mean age, higher body mass index, vascular disorders and the negative effect of a chronic disease on mood. Pain was more frequent in the control than in the case group which could be due to a better sensation, compared to diabetics.

Loss of vaginal lubrication, reduced sensation and sexual pleasure in women with type 2 diabetes as observed in this study is similar to that reported by Meeking et al. [14] in type 1 and type 2 diabetic women. Similar observations have been reported by Fatemi and Taghavi [15] in type 2 diabetic women. In the investigation of Schreiner-Engel et al. [16] of cognitive, psychological, interpersonal, and sexual dimensions with diabetes, diabetic women showed a relatively low impairment in sexual responses, but sexual desire was significantly lower. The observations could be attributed to the changes in life style, psychological state, neurologic and vascular deficits during a chronic disease such as diabetes.

Pain disorders of 8.9% in our study was lower than the 26% reported by Safarinejad [17] in a population-based study of 2,626 women, aged 20-29 years. Probably, the wider age range of 20-55 years in our study could explain the difference between the two studies.

In conclusion, prevalence of sexual dysfunction in diabetic mellitus women and controls was high; however, as the number of cases was limited, further studies with a higher number of patients are needed to confirm the results.

The authors wish to acknowledge Prof. M. Baradaran for his technical assistance in the ophthalmologic examination of patients.

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