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General lnternal Medicine Female Sexual Dysfu nction Diagnosis and Testing Female sexual dysfunction describes sexual difficulties that are persistent and distressing to the patient. Abnormalities in female sexual response fall into three categories: . sexual interest/arousal disorder (lack ofsexual interest and responsiveness) r orgasmic disorder (absence ol orgasm fbllowing normal excitement phase) o genitopelvic pain/penetration disorder (difficulty or pain with penetration) A pelvic examination is helpful in identifying specific areas of pain or tenderness, vulvovaginal atrophy, decreased lubrication, or tissue friability. Screening for concurrent depression is indicated because sexual dysfunction and depression often coexist. Laboratory testing is recommended only if an underlying disorder is suspected. Treatment Treat underlying contributing causes (e.g., vaginitis, interstitial cystitis, pelvic adhesions, infections, or endometriosis). Use lubricants as first line therapy to alleviate dyspareunia from vaginal atrophy. Low-dose vaginal estrogen is second line therapy for women without contraindications to estrogen. Ospemifene is a selective ER modulator used to treat dyspareunia associated with vulvovaginal atrophy. Use CBT for depression or anxiety. Flibanserin may be used to treat women with low sexual desire; however, its use is limited by side effects. DOil'T BE TRICKED o Do not treat female sexual dysfunction with low dose testosterone or phosphodiesterase inhibitors Vaginitis Diagnosis Vaginitis is characterized by vaginal irritation, pruritus, pain, malodoq or unusual discharge. The three most common infectious causes ofacute vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and Trichomonos. Trichomoniasis is the only cause of vaginitis that is sexually transmitted.

DOil'T BE TRICKED o Do not treat female sexual dysfunction with low dose testosterone or phosphodiesterase inhibitors Vaginitis Diagnosis Vaginitis is characterized by vaginal irritation, pruritus, pain, malodoq or unusual discharge. The three most common infectious causes ofacute vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and Trichomonos. Trichomoniasis is the only cause of vaginitis that is sexually transmitted. STUDY fABIE: Diagnosis of Vaginitis Test Characteristics Physical examination Bacterial vaginosis: Thin, white discharge with "fishy" odor but without irritation or pain Candidiasis: External and internal erythema with itching and irritation; nonodorous; white, curd-like discharge Trichomoniasis: Frothy, yellow discharge; erythema of the vagina and cervix ("strawberry cervix") Vaginal pH (normal Bacterial vaginosis and trichomoniasis: >4.5 <4.5) Candidiasis: <4.5 "whiff" test Bacterialvaginosis: "Fishy" odor after adding KOH Microscopic Bacterialvaginosis: Squamous epithelial cells covered with bacteria that obscure edges ("clue cells") examination of Candidiasis: Budding yeast and pseudohyphae vaginalfluid Trichomoniasis: Motile trichomonads Other testing Nucleic acid testing is available for bacterial vaginosis and trichomoniasis (gold sta 159