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7 Articles in this Series
Addressing Arthralgia in Children
An ACR/ARHP Preview
Axial Spondylitis: Mimics, Progression, the Need for MRI, and New Management Recommendations
How Rheumatic Diseases Can Hurt Sexual Health
Tanezumab for Hip and Knee OA; Cosentyx for Ankylosing Spondylitis; and Upadacitinib for RA
Treating Chronic Musculoskeletal Pain in Older Adults
Uncovered Inflammatory Pathways of Osteoarthritis Call for New Targets

How Rheumatic Diseases Can Hurt Sexual Health

Being open with patients about the connections between joint and tissue pain, and their sexual function, may ease this QOL symptom. An ACR/ARHP 2018 annual meeting highlight, with Elaine Furst, BSN


Elaine Furst, BSN, is a nurse-educator and outreach director (and past chair) of the Scleroderma Foundation in Los Angeles. She has given workshops at multiple universities, including Johns Hopkins, and has had a career as a background actress. In a talk on “Sexual Health, Intimacy & the Effects of Rheumatic Disease” at the 2018 ACR/ARHP annual meeting in Chicago, she shared that studies going back to the 1960s reveal that rheumatic diseases increase risk of sexual dysfunction, with little insight into how to help these patients. Only 37% of specialists talk to their patients about sexual activity compared to 63% of OB/GYNs, she stated. Reasons given for not discussing the subject range from discomfort and lack of awareness on the part of the doctor, to feeling that this is the role of another clinician. However, not addressing the subject does a disservice to the patient who may not understand the connection between their rheumatic condition and possible sexual dysfunction.

Further challenging the current medical climate is that sexuality is not often covered in assessment tools, such as the HAQ-DI disability index and quality of life (QOL) instruments. Yet, having pleasurable experiences of all kinds, including sex, increases quality of life, from boosting immunity to decreasing reports of pain, said Ms. Furst.

Sexual activity can be impacted by rheumatic disease. (Source: 123RF)Sexual activity can be impacted by rheumatic disease. (Source: 123RF)

The Facts about Sex and Autoimmune Disease

Factors associated with sexual dysfunction in rheumatoid arthritis (RA) include limited mobility, pain, fatigue, depression, muscle weakness, and more (see Tristano, World J Orthop, 2014). In women with systemic sclerosis (SSc, or scleroderma), 30% were less likely to be sexually active and nearly twice as likely to have impaired sexual activity compared to normal controls (see Levis et al, A&R, 2012). Although the Levis study has flaws, Ms. Furst noted, due to the menopausal age range of subjects, its implications on scleroderma patients include worse lubrication and increased pain during intercourse.

The Role of Menopause

 “Menopause,” she reiterated, “is often not considered, but if you look at the symptoms (eg, increased vaginal dryness, loss of libido, depression), they certainly do get in the way of having a satisfying sexual experience,” said Ms. Furst. “When you have a chronic illness and add pain to all of this, it makes it worse.” She pointed out that the average patient in rheumatology is 40 to 60 years old, the prime menopausal age.

The Role of Medications
Ms. Furst reviewed how certain pharmacological treatments for rheumatic conditions and related symptoms may be impacting sexual function. SSRI anti-depressants and tricyclics, for example, may inhibit arousal and delay or prevent orgasm, and impair lubrication. Steroids decrease vaginal lubrication and narcotics, including morphine, decrease desire, while beta-blockers and calcium channel blockers impair lubrication in women and cause erection problems in men. Even NSAIDs can lower desire and cause vaginal dryness, she reported.

“Chronic autoimmune disease equals in one form or another, or one level or another, depression, decreased libido, fatigue, and pain,” she explained. “Add age and medications to the mix, and the combined physical and emotional impact is quite high.”

How to Talk to Patients about Sexual Pain

Most patients, not to mention most clinicians, do not make these connections. But having an open conversation with a patient may unlock new information and help improve his/her quality of life.

Look for anxiety and level of accommodation to the rheumatic disease, suggested Ms. Furst, as those can be a signal that the patient is experiencing other symptoms, such as sexual difficulties. Ask them about flares, stress, and relationship changes, and listen well. For instance, if the patient says, “I hope these Kegel exercises help,” ask what she hopes they may help with. Pay attention to the patient’s cues and concerns (eg, hip pain) that may be related to sex. This may help a clinician frame the subject or start a dialogue that the patient may be initially hesitant to discuss.

Consider Your Skill Level

It’s also important to consider your own skills, advised Ms. Furst. Are you comfortable talking about the subject of sex with your patients, she asked the audience? Can you say all the words? (Some clinicians are not comfortable with this aspect.) Are you prepared to answer specific questions and, if not, to refer your patient to someone who can help? “Unfortunately, we’re not taught to do ask these personal questions, but rather, taught not to intrude,” said Ms. Furst.

Let Patients Know They Have Options

Referring again to publications by Tristano AG, rheumatoid arthritis patients with sexual disability can change position or use heat and relaxation exercises before a sexual encounter, while those with dyspareunia can try lubricants and estrogen cream. In addition, rheumatologists can encourage patients to maintain a positive attitude and to take small steps toward intimacy; they may even encourage patients to use devices that may help or suggest medications that may be taken in advance of sexual activity.

Finally, Ms. Furst shared how many paraplegic and quadriplegic patients have been able to have satisfying sexual relationships; making scleroderma and other rheumatic patients who are facing sexual pain and related difficulties aware of this fact may change their expectations and lead to positive change in their own sexual lives.

At the end of the day, “more sex equals more sex,” she said, and that is likely a good thing.

Next summary: Tanezumab for Hip and Knee OA; Cosentyx for Ankylosing Spondylitis; and Upadacitinib for RA
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