Female Sexual Dysfunction Clinical Presentation

Updated: Oct 18, 2020
  • Author: Brett Worly, MD, FACOG; Chief Editor: Christine Isaacs, MD  more...
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Presentation

History

Many patients are reluctant to disclose sexual problems owing to social stigma; fear of embarrassment; nontraditional gender roles or different sexual orientation; concern about the embarrassment of the healthcare provider; distrust in the provider’s ability to help; or a history of sexual, physical, or emotional abuse. Using a routine screening question during history-taking is therefore essential to open a dialogue about sexual concerns. Examples of questionnaires include the 19 question Female Sexual Function Index, a 12 item Female Sexual Distress Scale, and the 4 item Brief Sexual Symptoms Checklist for Women. [15]  A thorough nonjudgmental sexual history with open-ended questions is vital to making a diagnosis of sexual dysfunction and to identifying contributing elements. Most elements of the sexual history will apply to any evaluation for sexual dysfunction; those that are particular to a specific diagnosis are outlined separately below.

Questions should specifically address the nature of the concern, and whether the patient has difficulty with sexual desire, arousal, orgasm, sexual pain, or some combination thereof.  It is important to understand how long the problem has lasted, and whether the onset was abrupt or gradual.  A temporal relationship to a historical element such as childbirth, assault, or surgery may shed some light on the cause of the problem. While sexual, emotional, or physical abuse may not be disclosed by the patient at the first interview, building trust within the healthcare provider/patient relationship is essential, as this may be disclosed at a later time.

A careful social history is important, which should explore the nature of the patient’s relationship with her partner, whether this problem existed with other sexual partners, and for whom the sexual problem is causing distress. It is also important to understand that not all patients have a heterosexual or a monogamous relationship, and for those healthcare providers with moral objections to a person’s sexual choices, referral to another provider who can professionally and objectively handle the sexual complaint is essential. A psychological history is important, eliciting elements such as depression symptoms, history of psychiatric disease, and any history of alcohol or substance abuse. Understanding what the patient has tried to resolve the sexual problem can also be an important window into the patient history. [16, 11]

Female Sexual Interest/Arousal Disorder

In taking a sexual history from a patient with a complaint of “low libido” or “decreased sex drive,” specific information about their libido is important.  The next step is to establish what the level of desire was at baseline before the patient detected a problem. Helpful questions might include whether the patient has any spontaneous sexual thoughts or fantasies, whether she masturbates, and whether she has ever initiated episodes of intercourse within the relationship.

Female Sexual Pain/Penetrative Disorder

Sexual pain is often classified as being insertional, which usually involves external or vaginal structures, or deep, which would suggest intraperitoneal structures as a source. The sexual history of a woman complaining of sexual pain should target the nature and severity of the pain, sexual positions associated with the pain, the location, whether the patient needs to stop intercourse due to pain, the time course, and the previous evaluation and interventions attempted.

Female Orgasmic Disorder

For those patients with a primary complaint of orgasmic difficulty, questions should be directed to their experience of orgasm. It would be important to know whether orgasm was achieved previously, and if so under what circumstances (eg, with vibratory stimulation, with the same or different partner, or in a particular environment). Asking about the patient’s expectations and her knowledge of her own anatomy may also be helpful. 

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Physical Examination

Most female sexual dysfunction (FSD) issues do not directly relate to physical findings, and the physical examination may be focused with the following in mind. Thyroid disease may be contributory to Female Sexual Interest/Arousal Disorder (FSIAD), and a thyroid examination may be included. Pelvic examination is most helpful in women who complain of sexual pain and should specifically look for findings of atrophy or areas of tenderness that may relate to their complaints. Some patients with a history of trauma or abuse may not be ready for a pelvic examination on initial evaluation, and pelvic examination may need to be delayed to accommodate patient needs.

In examining external female genitalia, look for any skin lesions or atrophy. For patients with sexual pain, performing the bimanual exam before the speculum exam is ideal, as a bimanual exam may cause less trauma to the vaginal tissues than the speculum. For some patients with severe sexual pain, the speculum examination causes substantial trauma, and a subsequent bimanual examination is inaccurate and invalid owing to residual pain from the speculum.

The bimanual examination should specifically identify areas of tenderness that contribute to pain with penetration.  Some specific areas of focus in the pelvic exam include the vulvar vestibule (as occurs with localized provoked vulvodynia), levator and perineal body muscle soreness (vaginismus), rectovaginal nodularity (endometriosis), pelvic side wall tension or tenderness (myofascial pain syndrome), and anterior wall/ bladder (interstitial cystitis or painful bladder syndrome). Cervical motion tenderness is a non-specific finding that may suggest some intraperitoneal inflammatory changes. [9]  Common gynecologic conditions including vaginitis, sexually transmitted infection, leiomyomata, endometriosis, adnexal masses, cervical cancer, vulvar dermatoses, pelvic organ prolapse, vulvodynia, vaginismus, and adenomyosis may be identified on pelvic examination. [11]

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