A 25-year-old woman presents to your office with complaints of pain during intercourse for 2 months. The pain occurs with initial penetration and continues throughout the entire episode. She relates that she and her husband have been married for a year and previously had a pleasurable, pain- free relationship. She tells you that she has been to several area doctors and had a "full work-up" without a diagnosis, including a pelvic examination, Pap smear with cultures, and pelvic sonogram. On examination, she has a normal pelvic examination with no pain. You are unsure of the differential diagnosis, so you continue taking more history. She admits to vaginal dryness and low libido during this same timeframe. You ask if anything in her life changed 2 months ago. She suddenly begins to cry and states she found evidence of her husband's infidelity 2 months ago. What is the most appropriate recommendation for your patient?
An organic cause of this patient's sexual dysfunction is unlikely. Her pain during intercourse, poor desire, and lack of sufficient lubrication probably stem from the psychological stress from her husband's infidelity. Marital counseling may aid in resolving the issues that resulted in the infidelity, and the aftermath. Female sexual dysfunction consists of four broad categories: dyspareunia, orgasmic disorder, arousal disorder, and impaired sexual drive. Sexual dysfunction may result from physical conditions, such as neuropathy or sleep deprivation, or from psychological conditions, such as depression or a history of abuse. A thorough evaluation should include medical conditions as well as psychosocial questions pertaining to the health of her relationship with her partner and personal issues that contribute to her sexual well-being. Topical intravaginal estrogens are useful for perimenopausal vaginal dryness, and vaginal dilators are often tried for vaginismus, but neither would help her obvious psychological distress. Antidepressants would not address the cause of her symptoms. Low-dose testosterone has not been approved for the management of hypoactive sexual desire disorder and would not address the cause of this woman's distress.
Marriage counseling
Estrogen vaginal cream for vaginal dryness
Vaginal dilators for treatment of vaginismus
Antidepressant therapy
Miscellaneous