Intimacy & Rheumatic Conditions

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.

Ara Dikranian, MD

“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?”

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.

When addressing how to deal with joint stiffness, pain and fatigue, which can make intercourse more challenging for both men and women, Dr. Dikranian suggests trying different sexual positions because some may be more comfortable than others. Also, it may work better to have intercourse in the evening rather than the morning, because joints may be less stiff at that time. To cope with pain, a patient may want to take medication to help it subside before being intimate with a partner. Practical measures, such as taking a warm shower or using massage as part of intimacy to help loosen joints, may also be beneficial.

Dr. Dikranian adds that his advice for discussions about intimacy issues with gay or lesbian patients is the same, because the challenges for heterosexual and homosexual patients are similar.

Other Resources
If an appointment doesn’t allow enough time to fully discuss an intimacy-related issue, perhaps an ancillary staff member, such as a nurse practitioner, nurse educator, therapist, counselor or social worker, can address their concerns. Rheumatologists may also want to point patients to a patient advocacy group, printed resources or websites, such as Arthritis.com. The ACR also has online resources  for patients and caregivers.

The bottom line: At minimum, a rheumatologist should initiate a conversation with their patients and ask if they have any intimacy issues. “Keep conversations nontechnical and on par with patients’ understanding. Provide resources and referrals to other providers who can spend more time on the topic or give more practical, specific advice,” Dr. Dikranian concludes.

Karen Appold is a medical writer in Pennsylvania.