Week 8 DB reply 1

Table 1: Terminology Definitions

Table 2: Female Sexual Dysfunction

Term Definition

Sexualit y

A broad concept encompassing sexual feelings, thoughts, attractions, preferences, and behaviors across a lifespan.

Sexual health

A state of physical, emotional, mental, and social well-being in relation to sexuality; not merely the absence of disease or dysfunction (WHO, 2022).

Sexual identity

How a person views themselves in terms of their sexual orientation and sexual expression.

Sexual orientat ion

A person’s pattern of emotional, romantic, or sexual attraction to others (e.g., heterosexual, homosexual, bisexual, asexual).

Sexual agency

The capacity of individuals to make informed, autonomous decisions regarding their sexual activity and expression.

Sex Biological characteristics assigned at birth based on anatomy and chromosomes (e.g., male, female, intersex).

Gender Identity

A person’s deeply held sense of their gender, which may or may not align with their sex assigned at birth.

Transge nder

A person whose gender identity differs from the sex they were assigned at birth.

Gender dyspho ria

Psychological distress resulting from a mismatch between one’s gender identity and assigned sex at birth.

Cisgen der

A person whose gender identity aligns with the sex assigned to them at birth.

Transm ale A person assigned female at birth who identifies and lives as male.

Transfe male A person assigned male at birth who identifies and lives as female.

Table 3: Vulvodynia and Vaginismus

SOAP Note

Patient Name: Gayle
 Age: 25
 Gender: Female
 Chief Complaint: "I'm here for my first Pap smear, but I’ve never been able to tolerate it before."

Category Examples

5 Medical (Physical) Causes

Diabetes mellitus, hypothyroidism, menopause (estrogen deficiency), chronic pelvic pain, multiple sclerosis

5 Medication- Induced Causes

SSRIs (e.g., fluoxetine), antihypertensives (e.g., beta-blockers), antipsychotics, opioids, hormonal contraceptives

5 Psychological Causes

Depression, anxiety, history of trauma or abuse, low self-esteem, relationship conflict

Management Plans

Pharmacologic: 1) Flibanserin (Addyi) for HSDD, 2) Vaginal estrogen for dryness and pain. 
 Non-pharmacologic: 1) Pelvic floor physical therapy, 2) Sex therapy or cognitive behavioral therapy (CBT)

Item Answer

Define Vulvodynia

Chronic vulvar pain without identifiable cause, lasting at least 3 months, often described as burning, stinging, irritation, or rawness.

Define Vaginismus

Involuntary contraction of pelvic floor muscles that interferes with vaginal penetration, often associated with fear, anxiety, or past trauma.

Difference Between the Two

Vulvodynia is primarily pain-based, occurring without muscle spasm; vaginismus is characterized by involuntary muscle tightening that prevents penetration.

Treatment Options

Vulvodynia: Topical lidocaine, low-dose tricyclic antidepressants, pelvic floor PT, CBT. 
 Vaginismus: Vaginal dilator therapy, pelvic floor PT, sex therapy, anxiolytics if anxiety is a factor.

S: Subjective

HPI: 
 Gayle is a 25-year-old woman presenting for her first Pap smear. She attempted a Pap smear once previously but could not tolerate speculum insertion due to pain at the vaginal introitus. She reports an ongoing history of pain with any attempts at vaginal penetration, including tampon use and intercourse. She first noticed pain at age 19 when she tried to use tampons. At 21, she attempted vaginal intercourse but experienced significant introitus pain that made penetration impossible. She has not had successful vaginal intercourse to date. The pain is described as sharp and located right at the opening of the vagina. There is no associated itching, discharge, or burning. She expresses high levels of anxiety surrounding pelvic exams and is tearful when discussing the procedure.

Menstrual History:

• Menarche at age 13

• Regular monthly menses, lasting 5-6 days

• Does not use tampons due to pain on insertion

• No reported dysmenorrhea or menorrhagia

Sexual History:

• Never able to complete vaginal intercourse due to pain

• One prior relationship ended due to sexual difficulties

• Denies history of sexual abuse

• No known history of sexually transmitted infections (STIs)

• Not currently sexually active

Obstetric History:

• G0P0

Gynecologic History:

• No prior Pap smears completed

• No history of gynecologic surgeries or procedures

• No vaginal infections or abnormalities noted previously

Psychosocial:

• College graduate, employed full-time

• Lives alone, strong support system

• Expresses guilt, shame, and embarrassment about inability to tolerate vaginal penetration

• High anxiety surrounding medical exams

Medications: None
 Allergies: NKDA 
 PMH: Unremarkable 
 PSH: None
 FH: Non-contributory 
 SH: Denies smoking, alcohol, or drug use

O: Objective

General: Alert, cooperative, visibly anxious, tearful during interview 
 Vital Signs: WNL 
 HEENT: Normal
 Neck: Supple, no lymphadenopathy 
 Cardiovascular/Respiratory/Abdomen: Unremarkable 
 External Genitalia Exam:

• External exam deferred due to patient anxiety and distress

• No vulvar abnormalities noted on brief inspection

• No visible lesions or discharge

A: Assessment

Primary Diagnosis:

• Genito-pelvic pain/penetration disorder (GPPPD) – ICD-10: F52.6

o Formerly classified under vaginismus and dyspareunia

o Characterized by persistent or recurrent difficulties with vaginal penetration, associated with pain, fear/anxiety, and pelvic floor muscle tension

Differential Diagnoses to Consider:

• Vulvodynia (N94.819)

• Pelvic floor muscle dysfunction

• History of trauma (denied by patient)

• Dermatoses or congenital anomalies (if later suspected)

P: Plan

Diagnostics:

• Pelvic exam deferred today due to patient distress and need for further evaluation and trust- building

• Consider use of pelvic floor physical therapy consult prior to attempting Pap

• No Pap smear today; discuss alternatives if clinically appropriate (e.g., self-sampling for HPV in the future, if evidence-based and accessible)

Referrals:

• Pelvic floor physical therapy – for evaluation and treatment of suspected pelvic floor dysfunction

• Sex therapist or psychologist – experienced in sexual health and genito-pelvic pain disorders

• Consider referral to gynecologist specializing in sexual dysfunction or vulvovaginal disorders if needed

Treatment/Education:

• Reassured patient that she is not alone and that this is a common condition

• Validated her emotions and normalized her anxiety

• Discussed that Pap smears can be deferred in special cases and alternative methods may be considered

• Introduced the idea of using vaginal trainers or dilators under professional guidance

• Educated on the nature of genito-pelvic pain/penetration disorder and the importance of a multidisciplinary approach

• Emphasized that the goal is comfort, not rushing into painful procedures

Follow-Up:

• Schedule follow-up in 4–6 weeks after initial therapy sessions for re-evaluation and to plan gradual introduction of pelvic exam if appropriate

• Patient encouraged to return sooner for any concerns or questions