In addition to causing pain, fatigue, stiffness, swelling and a host of other symptoms that affect a patient’s well-being, rheumatic conditions, such as rheumatoid arthritis, Sjögren’s syndrome, psoriatic arthritis and psoriasis, can cause psychological, emotional and physical problems, such as reduced libido, self-esteem issues, depression, physical deformities, vaginal dryness, erectile dysfunction or being out of shape, which can affect relationships and intimacy. Unfortunately, some patients, both men and women, find it difficult to ask their rheumatologists about these issues. “This [reluctance] may be caused by shyness or embarrassment, cultural norms, language difficulties or differences in age or gender between the patient and physician,” says Ara Dikranian, MD, rheumatologist, Cabrillo Center for Rheumatic Disease, San Diego.
“If these symptoms aren’t addressed, a patient may fall short of being satisfied with their disease management,” says Dr. Dikranian. He adds that patients may also be hesitant to bring up intimacy issues if their rheumatologist seems rushed or is focused only on objectively measuring their disease state.
In light of this inherent communication barrier, and because some rheumatologists may also find the subject uncomfortable, Dr. Dikranian offers multiple approaches for a rheumatologist to broach this subject with patients.
When to Raise the Topic
First, recognize that a patient may feel uneasy addressing this topic, so rheumatologists need to make a point to bring it up, Dr. Dikranian says. He uses a patient intake form, created by the ACR and published by Pfizer, designed for both sexes, to obtain a patient’s health history. The form has questions that are specific to men, such as if they have erectile dysfunction or prostate issues, such as penile discharge. For women, the form has questions specific to them, such as if they have vaginal dryness or any gynecological problems, such as unusual vaginal discharge. If a patient checks any boxes in the genital, urinary or psychological categories, it enables the rheumatologist to bring up the topic during an office visit.
“We know that psychological issues, such as depression, anxiety, excessive worry, difficulty falling or staying asleep, or stress, may be the basis or consequence of issues related to intimacy or difficulties in relationships. Therefore, an affirmative response to a problem in this area may be an opportunity to explore deeper,” Dr. Dikranian says.
Another way to raise the subject is to say to a patient of either sex, “Many of my patients with RA tell me that their pain, fatigue or joint stiffness is affecting their sex lives, and many female patients complain of vaginal dryness and have had difficulty with intercourse. Has this happened to you?” For men ask, “Some of my male patients complain of erectile dysfunction or have other intimacy issues. Have you had any issues regarding this?”