Evaluation of Female Sexual Function in Persons with Type 2 Diabetes Mellitus Seen in a Tertiary Hospital in South East Nigeria with Emphasis on Its Frequency and Predictors

Background women with diabetes are at increased risk of sexual problems, however, this problem is under reported hence the need for this study. Methods This was a cross sectional case-controlled study. Seventy-five consenting females with type 2 DM were enrolled from the Diabetes Clinic of the Federal Medical Center, Umuahia, while Seventy-five persons which included hospital workers and female companions of subjects were recruited as control. Sexual dysfunction in both groups was diagnosed and characterized using the female sexual function index (FSFI). Data obtained from this study was presented as Mean±SD and analyzed using SPSS 17 software. Results The mean age of the T2DM group and control were 44.5 years and 38.9 years respectively. The mean total female sexual score (TFSS) was 22.10±6.66 in the T2DM subjects, while in the control subjects, it was 22.43±5.29. This was not statistically significant. The FSF scores in the desire, lubrication and orgasm domains were all lower in the diabetic women and this was statistically significant (P< 0.05). The domains of pain and arousal were also lower in the diabetic women although this was not statistically significant (P >0.05). The proportion of diabetic females who reported problems in the arousal, lubrication, orgasm and pain domains were higher (40.0, 36.4, 32.7, 29.1) than the controls (27.9, 16.2, 14.7, 19.1) {p<0.05}. Conclusion The prevalence of female sexual dysfunction was high from our study. Similarly, the Female Sexual Function Index (FSFI) score was low in women with diabetes when compared with controls. The domains of arousal, pain, orgasm and satisfaction were the most affected domains in subjects with DM Age, marital status, BMI, FBS and hypertension were predictive of sexual dysfunction in the diabetic women.

Women are still viewed as sexual objects in some societies and as a result of this, they are 56 expected to accept sex and sexuality as a prelude for conception. Secondly, some societies view 57 women who raise the issue of their sexual dysfunctions as promiscuous, this inadvertently will 58 make them to conceal these challenges for fear of societal ridicule. In the early nineteenth century, before the discovery of insulin, sexuality was not a common topic of discourse neither 60 was it an area that had benefited from extensive research. The initially conceived idea about 61 sexual dysfunction in both sexes was, "If you do not ask about it, it does not exist." The 62 connection between diabetes and sexual function only began to be highlighted about a century 63 ago unfortunately; more attention was given to male dysfunction. Furthermore, most of the 64 publications placed emphasis on the effect of diabetes on male sexual function, not until the 65 famous reproductive endocrinologist: Robert Kolodny reported the relationship between 66 diabetes and female sexual dysfunction. 5 There are several causes of female SD and these 67 includes: vascular, neurological, endocrine and psychogenic causes, all these factors have been 68 identified in the aetiology of female sexual dysfunction. 6 Unlike male SD, female SD is majorly 69 influenced by psychogenic factors such as depression whose occurrence is more than double in 70 women when compared to their male counterparts. 6

71
The probability of a woman with diabetes developing sexual dysfunction is higher when 72 compared with those without DM. Sexual problems in women with diabetes could present in 73 various ways. Some of these problems include dyspareunia, inadequate vaginal lubrication 74 reduced arousal and desire. Even though there are studies on this subject from other parts of the 75 world, literature on this subject from Nigeria is scarce, hence the need for this study.

Methodology:
This was a cross sectional case-controlled study. Seventy-five consenting females with type 2 82 DM were enrolled from the Diabetes Clinic of the Federal Medical Center, Umuahia, Abia state.

83
The inclusion criteria include subjects married for atleast 1year and have had a stable marital 84 relationship. Patients who were on drugs like beta blockers and centrally acting drugs like alpha 85 methyldopa known to cause female SD were excluded. Seventy-five persons which included 86 hospital workers and female companions of subjects were recruited as control (these subjects 87 were screened for diabetes). The questionnaire was administered by both male and female 88 medical personnel in the diabetic unit who informed the subjects about the research and its 89 objectives and they were assured that confidentiality will be maintained during and after the 90 study. Information given was used only for the purpose of this study. All the staff working for 91 the study were trained and examined before the enrollment. Information obtained from study 92 and control subjects included age, marital status, educational status, employment history, drug 93 history, type and duration of DM, height, weight, body mass index, waist circumference, hip 94 circumference, and blood pressure. The weight obtained was recorded in kilograms (kg) to the 95 nearest 0.1kg and the height recorded in meters (m) to the nearest 0.01m. The body mass index 96 was calculated as the weight in kg divided by the square of the height in metres. 7 The waist 97 circumference was measured using a non-stretch metric tape and taken at the mid-point between 98 the rib cage and iliac crest while hip circumference was taken as the maximal circumference of 99 the buttocks. 8 100 Sexual dysfunction in both groups was diagnosed and characterized using the female sexual 101 function index (FSFI) 9 which is a specific, sensitive and standardized tool for diagnosing female 102 SD. The index is a 19-item questionnaire providing scores on six domains of sexual function 103 (desire, arousal, lubrication, orgasm, satisfaction, and pain) as well as a total score. 9,10,11 In 104 women, the minimum and maximum scores are respectively 2 and 36. Women with a score under 26 were classified as having sexual dysfunction. This cut-off point was the same figure   106 validated by other researchers. It is a well-accepted self-report instrument for assessing sexual 107 function of women world-wide. The data obtained from this study was presented as Mean±SD 108 and analyzed using SPSS 17 software.  Table 2). The proportion of persons who had some form of education was higher in the 118 control subjects than in patients with T2DM and this was statistically significant (p=0.02).A 119 greater majority of the control subjects were either self-employed or civil servants compared 120 with the subjects with T2DM, although this was not statistically significant (p=0.24). A higher 121 proportion of the control subjects were either overweight or obese when compared with subjects 122 with T2DM, this was not statistically significant (p=0.33). The prevalence of SD in this study 123 was 79.2% and the mean age was 47.3±7.9. The proportion of diabetic females who reported

129
Sexual dysfunction (SD) is known to be common in male and females with DM, although it is 130 grossly under reported in females with DM. The prevalence of female sexual dysfunction (FSD) 131 in this study was 29.1%. This is much higher than the 6.6% reported by Unadike et al 12 though 132 it is almost same as the prevalence reported by Enzlinet al 13 in the population they studied. sexual challenges considering the fact that his study was carried out almost a decade ago.

137
Women are becoming increasingly more informed and confident in expressing their opinions: 138 this could be responsible for obvious increase in prevalence. Other studies reported even higher 139 prevalence compared to findings in this study. 14,15 The complications of diabetes seem to have a 140 much bigger influence on sexual problems as noted in our study.

141
The mean (SD) ages of subjects with T2DM were higher than that of the controls and this was 142 statistically significant: increasing age was associated with the development of FSD. In studies 143 from other countries, the age of the study population may have affected the FSD prevalence in 144 such climes; a Nigerian study had much older subjects 16 while a Belgium study 145 enrolled the youngest participants . 13 In our study, both the prevalence and age were 146 moderate , similar to what was reported in a US study. Age has a significant impact on the 147 sexual function of a woman as increasing age may be associated with declining sexual interest.

148
With aging, women tend to experience hormonal changes such as estrogen/androgen reduction, study. This will influence expression of sexual opinions and thoughts and inexorably, cause the 168 women to suppress topics relating to their sexuality for fear of its negative perception from the 169 society. Thus, these sexual problems may go unreported.

170
Age, marital status, BMI, FBS and hypertension are predictive of sexual dysfunction in the 171 diabetic women . Higher BMI class is predictive of sexual dysfunction in the diabetic women: 172 this finding is similar to reports from a New York study. 23 In a study done in China, similar trend was reported although this was not seen in the non diabetic control group. Although study 174 comparison between nations is problematic because varying definition and research methods 175 were employed in these various studies. Another interesting finding from this study is the lower 176 BMI and difference in HC and WC in patients with diabetes when compared to the control 177 group. A possible explanation could be that in a patient with diabetes, a vital aspect of 178 management is lifestyle intervention with one goal being weight reduction. Therefore, it may not 179 be uncommon to see patients with T2DM having a lower BMI, difference in HC and WC. We 180 feel that there is need for more studies to further investigate the mechanisms of obesity and 181 sexual dysfunction in diabetic women.

182
The strength of our study lies in the use of the FSFI questionnaire, a validated instrument to 183 assess female sexual function which has been extensively used in studies. Limitations that arose 184 from this study include: This was a small study which should be considered exploratory, no 185 multiple comparison adjustments were made in the analysis; therefore a larger and specifically 186 designed study is needed to evaluate other clinical and metabolic abnormalities in patients with 187 SD Secondly, we did not consider sex hormones, history of reproductive system diseases and 188 other factors in this study.

190
The prevalence of female sexual dysfunction was high from our study. Similarly, the Female Sexual

191
Function Index (FSFI) score was low in women with diabetes when compared with controls. The women. There may be need for more research to look at the influence of diabetes type on sexual 195 function in order to explore various treatment strategies for this group of women.

198
Written informed consent was obtained from the patient for publication of this research article.

199
A copy of the written consent is available for review by the Editor-in-Chief of this journal.  the past 4weeks. Please answer the following questions as honestly and clearly as 296 possible. Your responses will be kept completely confidential. In answering these 297 questions the following definitions apply:

299
Sexual activity can include caressing, foreplay, masturbation and vaginal intercourse.

301
Sexual intercourse is defined as penile penetration (entry) of the vagina.

303
Sexual stimulation includes situations like foreplay with a partner, self-stimulation 304 (masturbation), or sexual fantasy. Did not attempt intercourse Almost always or always Most times (more than half the time) Sometimes (about half the time) A few times (less than half the time) Almost never or never 18. Over the past 4weeks, how often did you experience discomfort or pain following vaginal penetration?
Did not attempt intercourse Almost always or always Most times (more than half the time) Sometimes (about half the time) A few times (less than half the time) Almost never or never 19.Over the past 4weeks, how would you rate your level (degree) of discomfort or pain during or following vaginal penetration?
Did not attempt intercourse Very high High Moderate Low Very low or none at all