Discussing the topic of birth control with patients can also lead to a discussion about issues related to intimacy. If a patient asks whether their children have an increased risk of developing a rheumatic illness, you may have another opportunity to initiate the subject of sexual intimacy. Rheumatologists are well aware that methotrexate is contraindicated during conception attempts for men and women. So when prescribing this medication, Dr. Dikranian recommends telling patients up front that it can cause birth defects and asking patients periodically if they have plans to have a baby any time soon. He advises anyone taking methotrexate to use birth control to avoid unplanned pregnancies.
According to Dr. Dikranian, if patients say they are doing OK when asked how they are doing, don’t take their answer at face value right away—especially when seeing male patients, who are less likely to bring up sexual concerns. Due to societal norms, some men view intimacy challenges as a deficiency in their masculinity.
According to a patient survey, the RA NarRAtive, patients often feel uncomfortable raising concerns to a healthcare provider. In fact, one-third of surveyed patients with RA worried that if they asked too many questions, their provider would view them as a difficult patient or it would negatively affect their overall quality of care.
Dr. Dikranian says, “Be proactive, and ask probing questions, especially if any of their comorbidities [are] not addressed. The key is to approach the topic in a non-threatening way and keep the lines of communication open. Knowing that patients are unlikely to bring up the topic, it’s the healthcare provider’s responsibility to do so in whatever way seems most comfortable for them.”
Dr. Dikranian says many female patients may realize improvement in vaginal dryness by changing their medication or minimizing use. Using a lubricant can be beneficial during intercourse, as well. Vaginal dryness may also be due to something unrelated to their primary condition, such as aging or hormonal changes. For men with erectile dysfunction, he recommends one of multiple medications, such as sildenafil or tadalafil.
“Use [these possibilities] as a springboard to address the deeper issues that a patient’s symptom may be reflective of,” he adds. Take the same approach with decreased libido, which may be caused by anxiety, depression or another psychological problem, or fatigue, which can occur in both men and women. For men, erectile dysfunction may be a result of self-image issues, for example. Some treatments for mental health conditions can affect sexual function.
