June 13, 2019 Let's talk about sex and diabetes

Grace Leeder [00:00:05] Welcome everyone to Diabetes Canada's 2019 Type 1 webinar series. My name is Grace Leeder and I'll be your host today. We are delighted that you're able to join us today for the webinar entitled "Let's Talk About Sex and Diabetes". Now I would like to welcome our speaker Dr. Alice Cheng and thank her for joining us today. Before turning it over to Dr. Cheng I'd like to give you a brief introduction. Dr. Alice Cheng is an endocrinologist at Trillium Health Partners Credit Valley in Mississauga and St. Michael's Hospital in Toronto. She is an associate professor at the University of Toronto and was the chair of the 2013 Diabetes Canada Clinical Practice Guidelines. So without further ado I present to you Dr. Alice Cheng.

Dr. Alice Cheng [00:01:03] So thank you very much Grace for the kind introduction and thank you for the opportunity to discuss a very important topic, looking at sex and diabetes. And depending on the age of the audience listening this slide may look familiar to you. This is Salt-N-Pepa who had a very famous song called "Let's Talk About Sex" which is I think why we're here why we're here today is to discuss issues around sex and diabetes.

 [00:01:13] So the outline is we're going to talk about things to discuss with your partner. We're going to talk about male sexual dysfunction, female sexual dysfunction. And we're also going to talk about the effect of hormones on your diabetes particularly around your menstrual cycle. And as well around menopause and very importantly we're also going to talk about preparation for pregnancy to ensure that the best outcomes can occur.

 [00:01:41] So to start off let's say you are thinking about having sex for the first time or perhaps for the first time with a particular partner. What are some of the things that you need to prepare? What are some of the things that you have prepared in the past? For those of you who have already gone through this and what kind of advice would you give someone who is asking you this question? I would love for you to all just reflect on for yourself as to what are some of the issues that you think are important for someone living with diabetes to think about as they are preparing to have sex. So when I was first thinking about that question I sort of came up with this checklist of some of the items that I think are important to discuss when considering having sex and living with diabetes. I think the first and very important thing and this is true of those with or without diabetes is to talk to your partner. If there are questions that your partner may have because if your partner does not live with diabetes and they may have questions that they don't know how to ask and if you initiate that conversation then the questions can be asked. And then any nervousness you may have around the diabetes and how will that impact the sexual experience. So this is an opportunity to I think engage your partner in conversation and then there's the ever interesting debate of pump on versus pump off that would be an interesting debate to have at conference one day. And usually if I'm dealing with a live audience at this point I'll ask for a show of hands as to how many are pump ons and pump offs when they have sex and there's usually a good 50/50 distribution. So obviously it depends on the kind of sex one is having and location at which one may be having it but this is something that you do need to think about and obviously it also depends on the type of technology that you're wearing and whether there's tubing involved etc.. So that's something that's worth thinking about ahead of time so that you're not fumbling in the heat of the moment. And then there's the very important consideration about risk of hypoglycemia. Because remember sex is physical activity and the level of physical activity can obviously differ depending on the situation. So the risk of hypoglycaemia is ever present. So planning accordingly as you would for exercise whether that be pump removal reduction of bolus insulin or having a snack either during might be a bit hard but TV before or certainly after and having hypoglycaemia supplies. So those are the type of things that you just need to think about. And then finally a very important question around contraception. No contraception and frankly talking to your partner at the first and the fourth one's really apply to anybody choosing to have sex not necessarily just with diabetes but in the case of diabetes it's particularly important to think about contraception because as we'll discuss later there are important things that need to happen prior to conception and therefore having proper contraception will ensure that the pregnancy is appropriately planned and a common question I get is can a woman living with type 1 diabetes safely go on an oral contraceptive or birth control pill. And the answer is absolutely yes you can. You can do so safely. There are no added concerns in someone living with type 1. And of course you can also use condoms, you can use IUD or intrauterine device, you can use diaphragms, you can use all of the usual stuff anyone else can and definitely can safely use oral contraceptive. So now let's talk about different types of sexual dysfunction and we'll start off by looking at men and the kind of sexual dysfunction that they may experience.

 [00:05:19] So the forms of male sexual dysfunction are listed here.

 [00:05:23] A common one is low testosterone. Now low testosterone is a potential issue and anybody any male not necessarily someone living with diabetes but in someone living with diabetes the percentages in the literature are 30 to 40 percent amongst type 2 and 14 percent amongst type 1 diabetes. Now that the numbers here look quite different but I would interpret this cautiously because remember that Type 2 diabetes population tends to be considerably older on average and therefore age is still the biggest predictor of low testosterone. So that likely explains the difference that we see. Other types of disorders maybe a ejaculatory disorders having to do with either no ejaculation or retrograde ejaculation where it's going backwards into the bladder. These are things that can be seen with or without diabetes but a little more prominently in those with diabetes. And then of course erectile dysfunction is a common one that people are aware of and we talk about it a lot more now. Thanks to the Viagars and the Cialises of the world and all the TV ads that we see but that actually has been wonderful in that it has opened up that conversation and it's common. The number quoted here is 34 to 45 percent but I would argue that it may be even higher depending on the age group that you serve. So age is by far the biggest predictor. Other risk factors like having elevated blood sugars can affect erectile function, high blood pressure, high cholesterol, smoking can directly affect erectile function and the presence of obesity. So all of these things can result in erectile dysfunction issues and someone living with diabetes is at higher risk of developing any of these male sexual dysfunction conditions. However it's not specific to those living with diabetes.

 [00:07:15] So if we look deeper at low testosterone the symptoms of low testosterone are low sex drive, erectile dysfunction or reductions in motivation and perhaps muscle mass. These are some of the classic symptoms of low testosterone and if you think that you are experiencing any of those symptoms then I would strongly suggest that you raise this with your doctor at which point you will be asked to do blood work. The blood work is a fasting blood test that's done in the morning and it's checking your testosterone levels and at the same time the doctor will rule out any other potential causes of the low testosterone. But classically for just erectile dysfunction it's often not related to low testosterone but may in fact be related to other things which we'll talk about as we get to the section on erectile dysfunction.

 [00:08:05] If it turns out that you do in fact have low testosterone then there are good treatments for it. There is Andriol which is an oral medication for testosterone which is not the preferred mechanism only because of the absorption of Andriol is very much dependent on whether you've eaten food properly a sufficient fat in the food etc.. So it's not as reliable in terms of testosterone replacement. The gold standard would be injections of testosterone which would need to be given in either the arm or the buttocks every two to four weeks at a clinic. The pros of this approach is that you will get high testosterone levels but they're fluctuating so right after the injection your testosterone levels are very high and then over the subsequent two weeks the levels start to drop off. So people will notice some fluctuations in how they feel. Then of course there's the inconvenience of the needle and the inconvenience of having to go to a clinic. There is also now a nasal form where use a nasal gel that you can put into your nose which will allow for smoother distribution of the testosterone. And I think the most popular versions are the gels which can be applied on the skin. So usually on the shoulder area which will then allow for slow absorption over the course of the day. And the reason why these are preferred at this stage in time is because of the stability that this testosterone preparation causes. Now what if one has erectile dysfunction? So erectile dysfunction can be caused by a number of things and it could be hormonal as we already talked about the low testosterone. It could also be mechanical because you do need appropriate circulation in order for an erection to occur. Or it could be a neurologic because you also need the proper nerve endings and the signals to orchestrate the entire process. So erectile dysfunction can be multifactorial and therefore if one does in fact have erectile dysfunction it's very important to raise it with the doctor in order to say hey this is what's going on. And then you will get asked a number of questions checking out your libido et cetera and then ultimately there will be some blood tests that will be done in order to ensure that the hormone levels are adequate. Once those things are taken care of then the treatments are in fact available. Now the most common treatments are the pills. So here you see Viagra and Cialis as well as Levitra which are called on-demand treatments meaning these are therapies that are taken as needed around the time that sex is planned in order to allow for better circulation. But there is now also the option of daily Cialis which is a much lower dose. And the idea behind that is to have the medication around all the time in order for performance to be available at all times. So these are the different treatments available for erectile dysfunction. I think the key is to bring it up to the doctor talk about it and then treatments can then be offered. Now what about female sexual dysfunction. So female sexual dysfunction dysfunction is more complicated just as the female sex is more complicated than the male sex. This is no different when it comes to sexual dysfunction. And we'll now talk about the different types that are discussed in the literature.

 [00:11:29] So when it comes to female sexual dysfunction this can affect up to 71 percent of women living with type 1 and 42 percent of women living with type 2 diabetes. But I would interpret these data very cautiously because the definitions may differ from study to study. But the point is it exists and the four types that are usually discussed in the literature are female arousal disorder, female orgasmic disorder, sexual pain disorder or hypoactive sexual desire disorder. And this last one the hypoactive sexual desire disorder or HSDD is the one where there is potential therapies that can be offered and is the one that I'm going to focus on a bit more moving forward. So for hypoactive sexual desire disorder, or HSDD, the clinical manifestation is absence of sexual fantasies and absence of desire for sexual activity. Now you may look at that and think OK well some people are just like that. That's not necessarily a disorder. And you're absolutely right because the other key component for it to be considered a disorder, is that it actually has to bother the person if it causes significant personal distress or difficulties in interpersonal relationships then it is considered an actual disorder and something that may require medical treatment. Now when we think about the female sex drive. It is complicated. The analogy I would suggest it's like a cockpit of an airplane. Complicated lots of buttons lots of levers lots of things that could go wrong. Lots of things that could go right but definitely more complicated than perhaps our other alternative which would be the male sex drive. Because it could be argued that the male sex drive is as simple as an on an off switch. Now clearly this is shown as an exaggeration on the truth. However it is true that the female sex drive is quite multi layered and a large part of it has to do with what's going on upstairs in terms of our brains. Are we stressed out worried? Is the relationship okay? Are there body image issues? What are the million other things that one is having to deal with? Is one getting enough sleep etc. and those things are a very big part of female sex drive. Whereas for male sex drive those same things can of course affect a man who's having issues at home with the family or at work or whatever can obviously impact on male sex drive. But it is particularly pronounced in the female. So if we think about HSDD in diabetes specifically what are some of the features about diabetes that make HSDD more likely? Well atherosclerosis is an important one meaning narrowing of arteries. We know that those living with diabetes are at risk of narrowing of arteries in various parts of their body. For female sex drive, within the genitalia circulation is important for arousal to occur so clearly that can be affected. Nerve damage from diabetes can also affect the genitalia and cause reductions in sensation. Elevated blood sugars by themselves, untreated, may result in recurrent yeast infections which obviously would affect one's desire and perhaps reduce lubrication which can then make sex painful. Body image issues around weight, around devices they may or may not be wearing, scars that may be present, fear of hypoglycaemia, depression or anxiety, which is common in diabetes, and then some of the medications we use to treat things like blood pressure may also lower sexual desire. So these are all things that are common with diabetes patients that could then result in hypoactive sexual desire disorder.

 [00:15:29] So if you think you may have HSDD, what should you do? And I think the most important thing to do is to talk to your doctor about it because I have to say in medical school we are now trained to talk about erectile dysfunction. What we're not yet well trained on is talking about female sexual dysfunction. So therefore your doctor may not come out and ask you, which is unfortunate because you look at the statistics that are shown here, 72 percent of women want to talk to their doctor but 73 percent would prefer that the doctor start the conversation. But yet we haven't done a good job teaching our medical students to have that conversation. So therefore the onus is unfortunately very much on the individual to actually bring up the topic. And if you bring up the topic then again you'll have a series of questions asked of you and then ultimately blood tests done to ensure that it is not a hormonal thing. More often than not it's not a hormonal thing. It's not a lack of estrogen, for example, because if you are still having periods then you are still having circulating estrogen. It likely has more to do with everything else going on and perhaps the other factors that were listed on the previous slide. So if one is diagnosed with each HSDD hypoactive sexual desire disorder then the most effective therapy is in fact cognitive behavioural therapy or psychotherapy or sex therapy which is very effective because again remember that there are two people involved when it comes to issues around sexual desire disorder and as well as I mentioned earlier a lot of female sex drive is from upstairs from the brain and issues around stress and relationships are critical to deal with. From a mechanical perspective virginal lubricants can be helpful in order to ensure that sex is at least comfortable. And then in terms of medication. So as you know on the male side of things we've got the Viagars and the Cialises of the world. On the on the female side not as much from a pharmacology therapy perspective. You can see the options listed in the table and the one that I would propose or highlight I should say is Flibanserin which is Addyi (A-D-D-Y-I). It is an oral medication that is approved in the U.S. but is also now approved in Canada as of around May of last year and it is an oral medication that works centrally. So sort of works at your brain in order to try to improve sexual desire. It's primary side effect is lower blood pressure and alcohol can make that lower blood pressure worse. So therefore when taking this medication alcohol is not something that should be taken at the same time. And if you have a tendency towards low blood pressure then this would be a problem. But this is really the only oral medication that's been found to have any kind of improvement. The other things listed there like testosterone, completely off label, can result in some other issues like hair growth. For example Buproprion is used for other reasons in terms of depression and may have been reported to improve sexual function but it's quite soft in terms of the data. And then Viagra in a woman is usually not effective. So therefore we don't have a lot of pill medications to look at but the Addyi is something that could be considered. So now we're going to change gears and talk about hormones and how hormones could potentially affect your diabetes.

 [00:18:54] So let's start off with the menstrual cycle. Now for those of you in the audience who are having periods or had periods you will know what I'm talking about when I talk about the fact that the hormones are in fact cycling. Over the course of the month, you're feeling different things because the hormones are rising at different levels and perhaps the one to focus on on this panel is actually the middle section which is the orange line and the dotted green line. Let's start off with the orange line. So first of all a classic cycle is classically 28 days and day one of a cycle is the beginning of your period. And then there's the follicular phase which is the first 14 days. There's ovulation and then there's the luteal phase which is the latter half of the cycle. Now if you focus first on the orange line you'll see that as your period starts your estrogen levels are fairly low and then they sort of creep up over the course of the month and then as you approach the time of ovulation there's a surge in the estrogen. That orange line bumps up and then once ovulation occurs the orange, the estradiol levels, estrogen levels fall a little bit and then they're kind of relatively flat for the rest of the cycle. And then just before the period starts the estrogen levels fall off. Now I want you to take a look at the dotted green line which is progesterone. Progesterone is a hormone that's made after you ovulate because after the egg pops out of the ovary, if you will, the remaining cells where the egg used to live start to transform and make this progesterone hormone. So for the first half of the cycle progesterone levels are negligible. And then once ovulation occurs in the egg pops out then you see the dotted line drive up and that's the progesterone levels rising and they rise rise and then sort of start to level off and then they fall off at the very end and that drop in progesterone is what induces a period. So if you think about the symptoms you experience during the cycle, this middle panel explains it all. So PMS happens after ovulation and it is due to the dotted green line and the progesterone levels being high. And that's what gives you PMS. If you think about sex drive often women will say that their sex drive goes up towards the middle of their cycle and that's that rise in the orange line. The estrogen just prior to ovulation which from an evolutionary perspective makes sense because interest in sex should be higher just before ovulation in order for procreation. So that's why that occurs on a physiologic level. But because these hormones are fluctuating throughout the cycle that can have impact on one's blood sugars. So when the follicular phase during the time of the period and just leading up to ovulation the estrogen rises slowly and your insulin requirements may go up a little bit but once the egg has popped and you've got the progesterone levels rising now you've become much more insulin resistance and you're actually going to need to take more insulin at that time. And then during the period itself, there's the lowest level of estrogen and progesterone and at that point your insulin requirements drop because your sensitivity is much greater. So what is the glycemic impact of the menstrual cycle? Well there's variable impact over the course of the month. So for the three to five days prior to your period you're going to find that your blood sugars are much higher and your insulin requirements tend to be increased. And then once the period starts your insulin requirements drop and your blood sugars start to be lower. So therefore it's important to be aware of this impact that the hormones are going to have on your blood sugars.

 [00:22:37] And as a result of those impacts during the PMS time, remember that part of PMS is also getting the munchies. So the more carbs that you're snacking on you have to ensure that you are bolusing appropriately for that. And don't be surprised if your sensitivity factor needs to change during that premenstrual timing. And then the premenstrual hyperglycaemia, your insulin requirements can go up by 10 to 15 percent and then the insulin doses need to be higher for about four to five days before your period. But once your period starts they need to drop back. And for those who are pumpers, it's usually temp basal's that you would have for pre and during period. Now what about menopause? Menopause is the other end of the spectrum. So as periods are stopping. How will that affect your blood sugars. So there's a lot of challenges during the time of menopause. In particular, you're still getting some periods but they're sort of sputtering and therefore you cannot predict when the period is going to occur and your blood sugars may fluctuate quite a bit which can certainly be frustrating during that time. The other frustrating piece is that hot flashes feel like hypoglycaemia so it's very easy to be confused as to what is actually happening. So the best strategies to take around that time and this sounds simplistic but is ideal is just do a lot of testing. If you do a lot of testing you have a better sense of where you are. And therefore be able to control things better and then realize that your blood sugar requirements, excuse me, your insulin requirements are going to fluctuate and that it may be very difficult to predict.

 [00:24:12] Now the final piece is what about pregnancy. So let's say you're considering pregnancy. So what do you do now? What do you need to think about? I think the most important advice to give at this point is to keep calm and to plan ahead. And the reason is because you need to make sure that you have planned ahead for the pregnancy with your health care team so that adjustments can be made and all of the necessary tools have been put into place and vitamins et cetera. And if those things are done then a wonderful outcome is expected out of the pregnancy with diabetes.

 [00:24:54] So what about the risk of fetal anomaly because that's often a question that I'll get asked is if I have diabetes I get pregnant what are the things I need to think about? Well well one of the concerns is the potential for abnormalities with the fetus.

 [00:25:11] Now this graph very nicely shows that the risk of abnormalities with the fetus is present regardless of whether or not you have diabetes. So even at the lowest A1C on the left hand corner you can still have a risk because that's just a risk of any pregnancy. But as the A1C levels rise you can see that the risk goes up. But it doesn't go up in a linear fashion it goes up in an exponential fashion meaning having a 10 percent A1C is much worse than having a 7 which is worse than having a lower number but by less of a percentage. So therefore trying to get the A1C down below 7 percent prior to conception is actually a critical component in preparing for pregnancy. Now in order to achieve that there is a checklist that we often talk about of things that we would like to see done prior to conception. So first of all prior to conception making sure that one uses reliable birth control until we've gotten all of these checklist components in check. Then we want to make sure that the preconception A1C is 7 percent or less. And the reason for that is that by the time a woman understands that she's pregnant she's often six, seven, eight weeks into the pregnancy at which point a lot of the important organs and spine and brain have already been developing. So we cannot wait to get control after a woman figures out she's pregnant. We need to have that control prior to conception so that for sure it's there at the time of conception.

 [00:26:50] There are certain medications we can and cannot use safely in pregnancy. When it comes to controlling glucose levels insulin is by far the safest and most reliable. Metformin and glyburide can also be used in pregnancy if you have type 2 diabetes. However it usually is not enough over the course of the pregnancy and insulin is usually required. We want to make sure that any diabetes complications have been addressed, specifically eye disease. So it's critical that an eye exam has been done prior to conception so that any eye damage can be fixed or treated or lasered before conception occurs.

 [00:27:30] And the reason is because pregnancy will worsen eye disease. So therefore if there is anything that might bleed as long as they get treated beforehand then it will not be a concern. Folic acid one milligram per day for at least three months before conception and at least three months after conception. Because this will reduce the risk of problems with the spine. And then stopping any other medications we may have started that can actually affect the fetus such as ACE-inhibitors / ARBs or statins. And one of the things that we know very well about type 1 diabetes in particular is that there's a study that's been completed, and Canada was a lead country for this particular study, is that the use of continuous glucose monitoring in pregnant women with type 1 diabetes resulted in some very positive outcomes including reductions in extra large babies, reductions in the need for a neonatal intensive care unit, reductions for hypoglycaemia in the baby and reductions in length of stay. So therefore for our ladies living with type 1 diabetes who are planning pregnancy we are often talking about getting CGM prior to conception and then continuing it through the course of the pregnancy. So to summarize. Sexual dysfunction is common. It's common in the general population and it's particularly common in those living with diabetes. Amongst men we think about low testosterone, erectile dysfunction. Amongst women, we think about the different types of disorder: female arousal disorder, female orgasmic disorder, issues around hyperactive sexual desire. And then for the hormones remember that especially around the period just before the period your insulin requirements go up. During the period the insulin requirements drop. And then of course in menopause things are fluctuating so it's important to check. And then finally for pregnancy, planned for pregnancy. Everybody should have their pregnancy plannediIf they live with diabetes. And remember that checklist of things that we need to consider to ensure that it's a safe and excellent pregnancy. And then finally talk talk talk talk talk. I think that the more we talk about sex in diabetes the more comfortable people will get. If you have any questions or concerns raise them with your team and the team will be happy to help address them with you. So make sure we have a good conversation with your team and good conversations with your partner. So thank you very much for your attention. And in the immortal words of George Michael. Sex is natural sex is good. Not everybody does it but everybody should. Sex is natural sex is fun. So I think it's something that we need to be comfortable talking about. And it's something that we could definitely all have treated. So with that I thank you for your attention. And I will pass it along over to.