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Women’s Sexual Health & T1D as We Age

What can change, why it happens, and what helps

The Big Picture

Sexual changes with aging are common—and they’re more likely and often earlier with diabetes because glucose variability can affect hormones, blood flow, nerves, the vaginal/vulvar tissues, and the urinary tract. The good news: there are many effective, low-risk options that improve comfort, desire, and intimacy at every age. The ADA’s 2025 Standards explicitly advise asking women with diabetes about sexual health and symptoms of genitourinary syndrome of menopause (GSM). Diabetes Journals+2Diabetes Journals+2 (Section 4.19 for Men’s Health, Section 4.20-4.21 for Women’s Health)

What can change

  • Vaginal dryness and pain with sex (dyspareunia). Often part of GSM, which reflects low estrogen in vulvar/vaginal/urinary tissues after menopause; symptoms include dryness, burning, irritation, reduced elasticity, and pain. AUA
  • Lower desire, arousal, or difficulty reaching orgasm. These may reflect cardiometabolic factors, neuropathy, mood or sleep problems, medication side effects, or relationship stress—commonly overlapping. PubMed
  • Recurrent “yeast” infections and UTIs. Diabetes (especially with hyperglycemia) raises the risk of recurrent vulvovaginal candidiasis (RVVC) and recurrent urinary tract infections. These can worsen pain and desire, and they’re treatable. PMC+2NCBI+2
  • Pelvic floor issues and vulvar pain. Pelvic floor over-activity or neuropathic pain (e.g., vulvodynia) can cause burning or pain with touch/penetration. Work-ups and targeted therapy help. PMC+1

Why it happens (the common drivers)

  1. Hormonal changes (menopause → GSM). Estrogen/androgen decline thins and dries the vaginal epithelium and affects urinary tissues, raising friction and UTI risk; diabetes can compound symptoms. AUA
  2. Microvascular and neuropathic effects of diabetes. Similar to the feet/eyes, small-vessel dysfunction and neuropathy can reduce genital blood flow and sensation, affecting arousal and orgasm. PubMed
  3. Infections & microbiome shifts. Higher glucose favors Candida overgrowth; RVVC and dysbiosis can perpetuate pain and dryness. PMC+1
  4. Medications and comorbidities. Some antidepressants (SSRIs/SNRIs) and certain antihypertensives can dampen desire/arousal or contribute to pain; depression, anxiety, and sleep apnea also matter. (Never stop a medicine without medical guidance—alternatives often exist.) PMC+2PMC+2

What you can do (step-by-step)

1) Start with the foundations (often surprisingly effective)

  • Glycemic tune-ups (fewer highs/lows) can reduce yeast infections and improve tissue comfort. PMC
  • Sleep & mood check. Treating depression/anxiety or sleep apnea can improve sexual symptoms and energy. PMC
  • Medication review. If sexual symptoms began after starting an SSRI or a BP med, ask about options with fewer sexual side effects (e.g., bupropion for depression; ARB/ACE-I or CCBs for BP in many cases). MDPI+1
  • Comfort aids for intimacy. Use vaginal moisturizers several times weekly plus lubricant for sex; plan timing around CGM/insulin to avoid hypos during intimacy. (Small adjustments go a long way.) NCBI

2) Evidence-based medical options (discuss with your clinician)

For dryness & pain (GSM):

  • Low-dose vaginal estrogen (cream, tablet, ring) is first-line and highly effective for dryness, pain, and urinary symptoms—minimal systemic absorption and generally safe for most women. Vaginal DHEA (prasterone) or ospemifene (a pill) are alternatives; choose based on preferences and medical history. Energy-based vaginal devices aren’t supported by high-quality evidence. NCBI+2Effective Health Care+2

For low desire/distress (HSDD):

  • After addressing GSM, mood, sleep, and meds, systemic transdermal testosterone (low-dose, off-label in the U.S.) can be considered in carefully selected postmenopausal women with persistent, distressing low desire—per the ISSWSH clinical guideline—with safety monitoring. ISSWSH+1

For recurrent infections:

  • RVVC: Options include extended/maintenance antifungal regimens. For postmenopausal or otherwise non-reproductive-potential women with RVVC, oteseconazole (VIVJOA®) is FDA-approved to reduce recurrences (not for women who could become pregnant). FDA Access Data+1
  • Recurrent UTIs: Work with your clinician on prevention (hydration, vaginal estrogen for GSM, targeted antibiotics when needed) using urology guidance that emphasizes avoiding unnecessary antibiotics. AUA+1

For pelvic floor or vulvar pain:

  • Consider pelvic floor physical therapy, trigger-management, and a vulvar-savvy clinician; vulvodynia is real and treatable, though it often needs a multi-modal plan. PMC

For relationship/psychological factors:

  • Sex therapy (solo or with a partner) helps with anxiety, communication, and adapting intimacy routines—useful alongside medical care. ACOG/ACOG-aligned resources support a biopsychosocial approach. The ObG Project

What to ask at your next visit (a 5-minute checklist)

  • “I’d like help with vaginal dryness/pain/desire—can we screen for GSM and talk about vaginal estrogen/DHEA/ospemifene options?” NCBI+1
  • “Can we review my meds (antidepressant/BP) for sexual side effects and consider alternatives?” PMC+1
  • “If my desire stays low after GSM treatment, could we discuss testosterone per ISSWSH guidance and what monitoring would look like?” ISSWSH
  • “I’m having repeat yeast infections/UTIs—what’s the best prevention plan for me? Am I a candidate for oteseconazole (if not of reproductive potential)?” FDA Access Data

Key, current sources (for your reference list)

  • ADA Standards of Care 2025 – recommends asking women with diabetes about sexual health and GSM; integrates psychosocial screening. Diabetes Journals+2Diabetes Journals+2
  • AUA/SUFU/AUGS Guideline on GSM – identification and treatment options (local estrogen, DHEA, ospemifene; shared decision-making). AUA
  • AHRQ 2024 GSM Evidence Review – strong evidence for vaginal estrogen, DHEA, and ospemifene; limited evidence for energy devices. Effective Health Care
  • ISSWSH Testosterone Guideline (J Sex Med) – how/when to consider systemic testosterone for postmenopausal HSDD. ISSWSH
  • Female sexual dysfunction & diabetes—mechanisms and care (2022–2025 reviews) – pathophysiology (vascular, neuropathic, hormonal, psychosocial). PubMed+1
  • Recurrent infections: diabetes and RVVC (2023–2025 reviews) and oteseconazole FDA label and VA monograph; recurrent UTI guideline. AUA+3PMC+3FDA Access Data+3
  • Medication effects: antidepressant-associated sexual dysfunction (2024–2025); hypertension therapy and female sexual function (2022 review). PMC+2PMC+2

Final Thought

With T1D, sexual well-being is absolutely within reach. Treat tissue comfort first (GSM), review mood/sleep/meds, address infections, and then personalize desire/arousal support (including sex therapy and, when appropriate, testosterone per guideline). Small steps often yield significant improvements in comfort, confidence, and connection.

 

Additional Resources

T1D and Menopause

A FAQ list from T1D Exchange on how to manage menopause with T1D

Midlife Women Are Clamoring for Testosterone. Does It Work?

Last updated 09/22/2025.