Evaluation of Female Sexual Dysfunction

FSD Overview - Defining Desire's Dip

• Female Sexual Dysfunction (FSD): Clinically significant disturbance in a woman's ability to respond sexually or experience sexual pleasure.
• Key Criteria: Causes personal distress; present for ≥ 6 months (not solely due to nonsexual mental disorder, severe relationship distress, other significant stressors, or effects of a substance/medication).
• DSM-5 Major Types:
  • Female Sexual Interest/Arousal Disorder (FSIAD): Absent/reduced sexual interest, thoughts, fantasies, initiation, pleasure, or arousal (genital/non-genital).
  • Female Orgasmic Disorder: Marked difficulty, infrequency, or absence of orgasm; or markedly reduced intensity of orgasmic sensations.
  • Genito-Pelvic Pain/Penetration Disorder (GPPPD): Persistent/recurrent difficulties with one or more: vaginal penetration, vulvovaginal/pelvic pain during intercourse, fear/anxiety about pain, or pelvic floor muscle tensing during attempted penetration.

⭐ FSIAD is the most commonly diagnosed FSD, characterized by a significant lack of, or reduction in, sexual interest and/or arousal for at least 6 months, causing clinically significant distress to the individual.

Etiology of FSD - Unraveling the Knots

• Biological Factors:
  • Hormonal: ↓Estrogen (e.g., menopause, lactation), ↓androgens, ↑prolactin, thyroid dysfunction.
  • Vascular: Atherosclerosis, peripheral vascular disease (PVD) → ↓genital blood flow.
  • Neurological: Multiple sclerosis (MS), diabetes (neuropathy), spinal cord injuries.
  • Medications: SSRIs, antihypertensives (β-blockers, diuretics), OCPs, antiandrogens.
  • Chronic illness: Diabetes mellitus, CKD. Pelvic surgery/trauma (e.g., hysterectomy).
• Psychological Factors:
  • Mental health: Depression, anxiety disorders (GAD, panic), PTSD.
  • Stress, negative body image, history of sexual trauma/abuse.
• Interpersonal Factors:
  • Relationship discord, poor communication, partner's sexual dysfunction or health issues.
• Sociocultural Factors:
  • Restrictive cultural/religious norms, lack of comprehensive sex education, societal pressures.

⭐ SSRI-induced sexual dysfunction is common; consider bupropion or mirtazapine as alternatives if FSD develops and psychiatric stability allows a switch or augmentation strategy under guidance.

History Taking in FSD - The Patient's Story

• Sexual History (DAPO 📌):
  • Desire (↓libido), Arousal (↓subjective/physical), Pain (dyspareunia, vaginismus), Orgasm (anorgasmia).
  • Onset, duration, severity, context.
  • Partner factors: health, sexual function, relationship.
• Medical/Surgical History:
  • Illnesses: DM, HTN, thyroid, neuro, depression/anxiety.
  • Meds: Antihypertensives, OCPs.

    ⭐ SSRIs are a common iatrogenic cause of FSD, particularly affecting orgasm and libido.

  • Surgeries: Pelvic, GYN, breast.
• Obstetric/Gynecologic History:
  • Menopause, childbirth (trauma), lactation.
  • Contraception, STIs, endometriosis.
• Psychosocial History:
  • Mood disorders, stress, relationship dynamics.
  • History of abuse, body image concerns.

Exam & Investigations - Clues & Corroboration

• Physical Examination:
  • General: BMI, BP; signs of systemic illness (thyroid, diabetes, androgen excess).
  • Pelvic Exam:
    • External Genitalia: Atrophy (thinning, pallor, loss of rugae), lesions, clitoral health.
    • Vaginal Mucosa: Dryness, pallor, petechiae (Genitourinary Syndrome of Menopause - GSM), discharge, pH.
    • Tenderness: Q-tip test (vestibulodynia), Pelvic Floor Muscle (PFM) palpation for trigger points.
    • PFM Function: Tone (hyper/hypo), Kegel strength, relaxation.
    • Masses, prolapse, structural issues.
• Investigations (Guided by Findings):
  • Hormonal Profile (if indicated):
    • Estradiol, FSH (suspected menopause/hypoestrogenism).
    • Testosterone (total & free for persistent low libido).
    • TSH, Prolactin (thyroid/pituitary screen).
  • Validated Questionnaires:
    • Female Sexual Function Index (FSFI): Assesses 6 domains (desire, arousal, lubrication, orgasm, satisfaction, pain).

      ⭐ FSFI score < 26.55 strongly suggests FSD.

  • Others (as indicated): Glucose/HbA1c, Pap smear, wet mount/cultures, pelvic USG.

High‑Yield Points - ⚡ Biggest Takeaways

• FSD evaluation uses a biopsychosocial approach for its multifactorial nature.
• Thorough history (sexual, medical, psychosocial, relationship) is key for diagnosis.
• Validated tools like FSFI (Female Sexual Function Index) quantify sexual function and distress.
• Focused physical exam detects pelvic pathology, atrophy, or pain triggers.
• Hormonal tests (estrogen, androgens, thyroid) for low libido or menopausal signs.
• Diagnosis follows DSM-5 criteria for specific disorders like FSIAD, FOD, GPPPD.
• Screen for drug side effects (e.g., SSRIs) and comorbidities (diabetes, depression).