Evaluation, assessment, and diagnosis

For a comprehensive assessment of the presenting sexual complaints, the healthcare providers should attempt to elicit a detailed account of the past, recent, and present sexual history.

To break the ice, it may be helpful to include a brief checklist for the sexual concerns within the OBGYN health review (Table 60.1). Although about a third of women with distressing sexual concerns are likely to seek professional help, embarrassment may preclude discussion in the rest and a majority also reportedly wait for the healthcare professional to initiate the discussion (1). In the literature, an open dialogue by the health worker minimized stigma and normalized the importance of sexual health while increasing the probability of sharing the delicate sexual history. In conservative societies, women may regard the confines of the OBGYN office as a safe haven for frank disclosure and treatment seeking (6). All these findings reiterate the need for having professionals who are comfortable in initiating these discussions.

Important within the complexity of diagnosing the specific sexual dysfunction is a comprehensive assessment for any coexistent organic or medical condition through relevant screening history. That notwithstanding, a number of psychological, sociocultural, interpersonal factors as also the partner's general and sexual health and relationship difficulties require specific assessment, prior to making a provisional diagnosis. Essentially, the different forms of sexual disorders are distinguishable through a detailed sexual history. Some pertinent information on the type of sexual dysfunction may evolve from the nature of sexual behaviour, safe sex practices, or partner's relationship issues (36) and therefore, the history needs to be viewed as an essential part of the diagnostic algorithm. Albeit difficult in a busy clinical setting, the history should be tailored to help determine the true underlying cause and the level of personal impact of the disorder.

Open-ended questions are sometimes vital to gain adequate information; in a patient-centred approach and through rapport creation, the next or follow-up visits may also provide cumulative history for arriving at a diagnosis.

Also in this context, a number of symptom scales or screening tools have been developed over the years and validated through studies to help the clinicians in identifying and differentially diagnosing women's sexual disorders. These instruments are useful to assess the changes in normal functional level and to determine the progress with any administered therapy. Screening tools are routinely used in clinical and academic research as important outcome measures for the qualitative and quantitative impacts. One of

Table 60.1 Female sexual dysfunction: a short screening questionnaire as a reference guide in the initial workup

No.	Question	^Yes	^No
1	Do you experience interest for sexual activity?
2	Are you aroused by the foreplay?
3	Do you normally have adequate lubrication?
4	Do you ever 'freeze up', making penetration impossible?
5	Do you generally have orgasm during sex?
6	Is intercourse always pain-free?
7	Are you satisfied with your sexual quality of life?

the earliest examples is the Female Sexual Function Index (FSFI), a self-reporting reference tool of 19 items, used in clinical trials to provide point scores for major sexual domains, viz. desire, arousal, lubrication, orgasm, and sexual satisfaction and it also includes assessment for pain (37).

Thus, valuable information can be gathered from detailed medical and OBGYN history, clinical data on physical and psychological health status, and reports from laboratory investigations for any undefined hormonal imbalance, in the systematic process of evaluation, assessment, and diagnosis of FSD.

In summary, the key points in the management algorithm of a woman's sexual problem include a comprehensive medical, sexual, psychological, and sociocultural history, any psychiatric condition suchasdepressionoranxiety,aswellastheprescriptionmedication(s) taken for coexistent clinical disorders. Oral contraceptive use needs to be queried for its possible impact on desire/arousal. A physical examination is imperative in cases of genitopelvic/penetration disorders, pelvic trauma, or history suggestive of herpes or lichen sclerosus. Menopausal evidence of vulvovaginal atrophy may cause an effect in dyspareunia, with negative impacts on sexual desire. Independent of age, a detailed genital health assessment will rule out sensory changes of vulval vestibulitis or provoked vulvodynia, involuntary pelvic floor muscle contraction, or pelvic organ prolapse. Since sex steroid hormones are critical for the structural and functional integrity, laboratory investigation for their circulating levels may be sometimes indicated, guided by specific history and/or physical findings. Of equal relevance is the measurement of prolactin levels or thyroid function tests in women with clinical evidence of hyperprolactinaemia or thyroid disease states. In as much as the importance of organic factors is felt in the expression of sexual impairments, women with chronic diseases need to be assessed for the potential impact of the disease process on their sexual health and life quality (4). Conforming to clinical data, in patients with cancer and receiving treatment, the incidence of FSD can be up to 90% after chemotherapy, 9% following surgical intervention, and 3% after radiotherapy (31). Furthermore, premature precipitation of menopause secondary to such therapies can drastically impair the sexual function through multiple mechanisms. Decreased sexual desire/arousal is to be anticipated if the interventions impair sensations in the breast or clitoris. In addition to altered body image, other factors that play an important role in reducing or eliminating sexual interest would include fatigue, debility, and family or relationship demands.

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Source: Arulkumaran S., Ledger W., Denny L., Doumouchtsis S. (eds.). Oxford Textbook of Obstetrics and Gynaecology. Oxford University Press,2020. — 928 p.. 2020

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