Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 54-year-old woman is evaluated during a routine examination. She is very concerned by her lack of interest in sexual intercourse. The patient feels like she “just doesn’t want to be touched.” She used to enjoy intercourse and does not know why she feels this way now, but she acknowledges that it is causing tremendous stress in her marriage. She has been menopausal for the past 2 years. She uses lubrication for intercourse, which is successful in reducing discomfort. She has no previous history of menstrual irregularities, pelvic surgeries, sexual trauma, or sexually transmitted infections. She currently takes calcium and vitamin D supplements daily.

On physical examination, external genitalia are normal, with no pain with vulvar palpation or with speculum insertion. The vaginal walls are pale with decreased rugae and petechial hemorrhages. Decreased vaginal lubrication is noted. The remainder of the physical examination is normal.

Which of the following is the most likely diagnosis?

A) Dyspareunia
B) Hypoactive sexual desire disorder
C) Sexual aversion disorder
D) Vaginismus

MKSAP Answer and Critique

The correct answer is B) Hypoactive sexual desire disorder. This item is available to MKSAP 16 subscribers as item 5 in the General Internal Medicine section.

The most likely diagnosis is hypoactive sexual desire disorder (HSDD). Female sexual dysfunction, defined as sexual difficulties that are persistent and personally distressing to the patient, affects up to 35% of sexually active women and is common among middle-aged women. HSDD is defined as a persistent lack of desire for or receptiveness to sexual activity or a persistent lack of sexual thoughts. HSDD is one of the most common causes of female sexual dysfunction, and prevalence ranges from 12% to 19%. Natural and surgical menopause may contribute to the development of HSDD, as the associated decline in testosterone levels may decrease sexual motivation and desire. There is no FDA-approved medication for the treatment of female HSDD; individual and couples sex therapy or psychotherapy may be beneficial.

Dyspareunia is persistent urogenital pain that occurs around intercourse and is not related exclusively to inadequate lubrication or vaginismus. Several conditions may cause dyspareunia, including interstitial cystitis, pelvic adhesions, infections, endometriosis, pelvic venous congestion, and vulvodynia. Treatment is aimed at correcting the underlying abnormality. This patient’s absence of sexual pain, history of previously normal sexual intercourse, and lack of symptoms and signs associated with any of the aforementioned conditions (no urinary symptoms, no history of pelvic surgeries or sexually transmitted infections) make dyspareunia an unlikely etiology for her current sexual problems.

Sexual aversion disorder is a persistent or recurrent aversive response to any genital contact with a sexual partner. Physiologic responses often accompany these feelings, with associated nausea and shortness of breath. Frequently there is a history of a painful or traumatic sexual event. Although this patient is avoiding intercourse, this is related to low sexual desire and motivation. Patients with sexual aversion disorder avoid intercourse because of feelings of revulsion and disgust.

Vaginismus is involuntary and recurrent spasm of the outer third of the vaginal musculature that interferes with vaginal penetration. Pain may accompany this involuntary spasm, and there is often associated avoidance and anticipatory fear of penetration. Prevalence ranges between 1% and 6%. On examination, this patient easily tolerated insertion of the vaginal speculum without any evidence of muscular spasm, although it should be noted that some women experience vaginismus only during sexual activity (situation-specific).

Key Point

• Hypoactive sexual desire disorder, a common cause of female sexual dysfunction, is defined as a persistent lack of desire for or receptiveness to sexual activity or a persistent lack of sexual thoughts.

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