A systematic review of the literature was conducted. A search yielded 1104 articles and 11 studies were included in the meta-analysis.
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Sexual dysfunction (SD) in women with diabetes is a multifaceted complication driven by hormonal, neuropathic and psychosocial factors. It has been reported that the prevalence of SD is higher in women with type 1 diabetes compared to both women with type 2 diabetes and women without diabetes. However, prevalence estimates of SD in women with type 1 diabetes are variable, due to the heterogeneity of the conducted studies and the various confounding factors that are associated with SD.
This review aimed to estimate the prevalence of SD in premenopausal women with type 1 diabetes compared to women without diabetes; consider current methods for measuring SD; and identify factors associated with SD in women with type 1 diabetes.
A systematic review of the literature was conducted. Four electronic databases (Embase, MEDLINE, CINAHL, PsycINFO) were searched between 15 March and 29 April 2022, the search was updated on 4 February 2023 to identify studies that assessed SD in women with type 1 diabetes.
The search yielded in 1104 articles; of these, 180 were assessed for eligibility. A meta-analysis of eight eligible studies revealed that the odds of experiencing SD is three times higher in women with type 1 diabetes compared to women without diabetes (OR = 3.8 95%CI 1.8–8.0, p < 0.001). The most commonly used measure of SD was the female sexual function index (FSFI); in three studies, this was combined with the female sexual distress scale (FSDS). Factors that have shown significant association with SD are depression, anxiety and duration of diabetes.
This review has shown that SD is a significant issue for women with type 1 diabetes. These findings should encourage diabetes professionals and policymakers to give more attention to female SD (FSD) by incorporating it into care pathways and clinical guidelines.
- The review shows that the odds of experiencing sexual dysfunction are three folds higher in women with type 1 diabetes compared to women without diabetes.
- The high prevalence of sexual dysfunction in women with type 1 diabetes highlights the need for a greater awareness and visibility among diabetes professionals and in clinical care delivery.
- There are currently no diabetes specific tools for assessing sexual dysfunction in women with type 1 diabetes, generic tools are used instead.
For those of you who don't remember, when 25 years ago Viagra first appeared, Pfizer was terrified that they would get attacked for promoting promiscuity by introducing a sex pill onto the market. Bob Dole was basically saying,
- "I have a medical problem. It's tough to talk about, but there is a treatment. I'm going to discuss the fact that I, among many other men, could use this to help that problem."
He was used in a way to deflect conservative or religious critics worried about the promotion of sex outside of marriage. Bob Dole was also well known to be married to Elizabeth Dole. This wasn't somebody who was out on the dating market. Bob Dole was a family man, and his selection was no accident. For all these reasons, Bob Dole was the first spokesperson for Viagra.
Now, as it happens, I had a role to play with this drug. Pfizer called me up and asked me to come and do a consult with them about the ethics of this brand-new treatment. I had never been asked by a drug company to do anything like this. I didn't know what I was doing. I thought about it and said,
- "I'll do it if you let me sit in on discussions and meetings at your New York headquarters about this drug. I want open access."
I assume they gave me open access. I went to many meetings before the FDA approved Viagra, and many discussions took place about how to roll it out. Once I got there, the one thing I insisted upon was that they had to be treating a disease. If they didn't want to get involved in criticisms about this new miracle solution to the age-old problem of sexual dysfunction, impotence wouldn't do.
- It wasn't a medical diagnosis, and it was kind of a very undefined situation.
I know we've gotten better at asking about this, but it's still difficult for patients to go into it, bring it up, and talk about it. It's something that we have to think hard about how we bring forward, honest, frank conversation and make people comfortable so they can tell us.
One thing that Viagra proved to the world is that not only is there a large amount of sexual dysfunction — some numbers as high as 35% of men over age 65 — but that sexual dysfunction is related to diseases. It's caused by hypertension, hardening of the arteries, and diabetes. It may be caused by psychological anxiety or even just a poor relationship where things are falling apart.
I think it's important that when Viagra first appeared, what Pfizer tried to do and with the marketing oriented around it was treating it as a disease, trying to treat erectile dysfunction as a symptom, and then trying to explore the underlying possible causes for that symptom.
Sadly, if we look today, we have come a long way — and not always a good way — from where Viagra started. Viagra is easily available online. Many companies say, just get online and a doctor will talk with you about a prescription.
They do, but they don't explore the underlying causes anymore online of what might be causing the erectile dysfunction. They certainly may have a checkbox and ask somebody about this or that, but I've gone and tested the sites, and you can get a prescription in about 30 seconds.
It's not really done with the old medical model that accompanied the appearance of Viagra. We now treat it as a recreational drug or an aphrodisiac, none of which is true. If your body is working properly, blood will flow where it's going to go. Taking Viagra or any of the other treatments will not help improve that or enhance that.
The other problem I see today with where we are with these impotence and erectile dysfunction drugs is that we still have not developed a full array of interventions for women.
- It's true that men have Viagra, and it's true that that's often reimbursed. We still have women complaining that they have sexual dysfunction or loss of interest or whatever the problem might be, and we haven't been able to develop drugs that will help them.
Since Viagra's approval 25 years ago until the patent ran out in 2019, $40 billion worth of the drug has been sold. Its advertising has shifted so that it's now online and available almost on demand. I'm not sure that path has been good, but it is a reminder to us, in this 25th anniversary year, that people care about sexuality.
Doctors always need to be thinking about exploring that and trying to get a vision or a view of the health of their patients. It's still hard for many people to speak up and say if they're having problems in bed, and we want to make sure that we try our best to make that happen.
Overall, I think the approval of Viagra 25 years ago was a very good thing. It brought a terrible problem out into the open. It helped enhance the quality of life for many men. Despite where we are today, I think the introduction of that pill was actually a major achievement in pharmacology.
I'm Art Caplan at the Division of Medical Ethics at NYU Grossman. Thanks for watching.
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