Approach Considerations

History-taking is the most important aspect of the workup for sexual dysfunction. It is crucial that the provider allow ample time for discussion of the patient’s concerns, which may sometimes require scheduling a separate visit. Establishing an honest and trusting relationship is important, and the provider should take care to explain the nature and purpose of intimate lines of questioning, and assure the patient that privacy and confidentiality are guaranteed.^{[16, 11]}

It is essential to meet the patient where they are with their problem, their requests and expectations, and their possible etiologies in setting up further diagnostic testing and treatment. A stated, negotiated treatment goal that is both fulfilling for the patient and medically reasonable given the situation may be helpful. For patients with female sexual dysfunction related to a trauma history, performing a pelvic exam may need to be delayed until further psychological treatment for the trauma can be obtained. Other patients may need marital counseling for relationship issues like poor communication or infidelity before real work on the sexual problem can begin. Patients with a psychiatric disorder may need to seek help for this issue before making real improvement with their sexual problem. A focused physical examination may or may not be appropriate, which can be determined after the history is obtained.^{[18, 16, 7, 11]}

Laboratory Studies

Many women with sexual concerns ask about or demand hormonal evaluation due to a perceived influence on sexual functioning. In truth, such testing is rarely helpful, as literature does not support a direct relationship between levels of either androgens or estrogens and the capacity for sexual desire or arousal.^[19]When use of supplemental hormone treatment is considered, the treatment is titrated to symptoms and not based on serum levels. Obtaining serum androgen levels may be useful as follow-up in women after treatment to prevent the exposure to supraphysiologic levels of androgens. The diagnosis of estrogen deficiency is usually made clinically based on symptoms of menopause, but estrogen or follicle-stimulating hormone (FSH) levels may be helpful when the diagnosis is in doubt, as in women post-hysterectomy. A thyroid-stimulating hormone (TSH) screen may be helpful for patients with Female Sexual Interest/Arousal Disorder to rule out thyroid etiology, particularly when other symptoms such as irregular menses are present.^[11]

Imaging Studies

Transvaginal ultrasound may be helpful for patients with sexual pain who have cervical, bladder, uterine, or adnexal tenderness or masses on pelvic examination. In the absence of a palpable lesion, imaging is rarely useful.^[11]

Treatment & Management

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