Approach
Diagnosis is based on a respectful but detailed history, preferably taken from both partners separately as well as together.[24][114] The detailed assessment not only allows subsequent therapeutic interventions but clarifies to the couple where the woman's sex response cycle is interrupted, which of itself is therapeutic.
History
The following ABCD mnemonic may be helpful.
What is the problem About?
Both partners' sexual responses are assessed.
Context: personal, interpersonal, and environmental.
Depression: current and past. This includes symptoms of major depressive disorder and persistent depressive disorder.
The following features of sexual functioning should be determined.
Problematic areas: desire/interest (motivation), subjective arousal (mental excitement) from various stimuli (e.g., physical or erotica, literature, or music), genital congestion and lubrication, genital sexual sensitivity, orgasm, pain or vaginal muscle tightness with, or preventing, intercourse or other vaginal penetration.
The duration (lifelong or acquired) and onset (gradual or sudden) of the problem, whether any type of sex between the couple occurs, the partner's sexual function, and whether the sexual problem is present in all situations, including self-stimulation (generalized) or only with specific activities/partners (situational).
Contextual factors personal to the woman: self-image, past sexual experiences, developmental history (including a history of trauma or sexual abuse); the current interpersonal relationship (degree of trust, respect, attraction, ability to be vulnerable); the sexual context (environment, type of sexual stimuli, religious and cultural aspects); and the woman's mood.
Previous experiences of sexual response (with past sexual relationships and past self-stimulation).
Any medical conditions or medications (especially antidepressants).[28]
Each partner's reaction to the problems and why they have presented for help now. If treatment has been sought in the past, inquiries should be made as to what they have tried, what has worked, and what has not.
Differentiating type of sexual dysfunction
When the woman reports lack of, or significantly reduced, sexual interest/arousal as manifested by at least three of the following indicators, then she is diagnosed with sexual interest/arousal disorder (SIAD):[1]
Absent/reduced interest in sexual activity
Absent/reduced sexual/erotic thoughts or fantasies
No/reduced initiation of sexual activity, and is typically unreceptive to a partner's attempts to initiate
Absent/reduced sexual excitement/pleasure during sexual activity in all or almost all (approximately 75% to 100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts)
Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual)
Absent/reduced genital and/or nongenital sensations during sexual activity (in all or almost all sexual encounters).
When the woman reports at least one of the two following symptoms, and experienced on all or almost all occasions of sexual activity, she is diagnosed with female orgasmic disorder (FOD):[1]
Marked delay in, marked infrequency of, or absence of, orgasm
Markedly reduced intensity of orgasmic sensations.
For both SAID and FOD, the symptoms above must have persisted for a minimum of approximately 6 months; must cause clinically significant distress in the individual; and must not be better explained by a nonsexual mental disorder, a consequence of severe relationship distress, other significant stressors, or effects of a substance/medication or another medical condition.[1]
When there is persistent or recurrent, unwanted or intrusive, distressing sensations of genital arousal (e.g., tingling, throbbing) that persist for ≥3 months and may include other genito-pelvic dysesthesia (e.g., burning, itching, pain), the diagnosis is persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD).[13] Symptoms are not associated with concomitant sexual interest, thoughts, or fantasies, and there is either limited resolution, no resolution, or aggravation of symptoms by sexual activity.[13]
All diagnoses are based on the patient's history. The degree of distress should be noted and specifiers as follows:[1]
Lifelong or acquired
Generalized or situational
Mild, moderate, or severe.
In addition to specifiers, other important clinical considerations can be highlighted in individual cases, including:
Partner factors (e.g., partner's sexual problems, partner's health status
Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity)
Individual vulnerability factors (e.g., poor body image, history of sexual or emotional abuse), psychiatric comorbidity (e.g., depression or anxiety), or stressors (e.g., job loss, bereavement)
Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity or pleasure, attitudes toward sexuality)
Medical factors (e.g., illness/medication) relevant to prognosis, course, or treatment.
Physical exam
In the context of medical disease, examination is important. In neurologic disease there may be sensory loss in the genitalia; in renal disease there may be anemia and vulvovaginal atrophy, both reducing sexual motivation; galactorrhea may suggest hyperprolactinemia; and loss of pubic hair may suggest hypoadrenal states. Pelvic and genital examination is necessary to exclude lichen sclerosis or other pathology when genital sexual sensitivity is reduced. It may also be done for reassurance in women who believe the cause of their sexual dysfunction is a problem of their genitalia (and is essential when dyspareunia is comorbid).
Investigations
Laboratory investigations are of limited use unless an underlying medical condition is suspected.[89] Baseline complete blood count, serum glucose level, and renal function tests may be used to rule out anemia, diabetes, or renal failure. Thyroid function tests and serum prolactin levels may be indicated if there are signs and symptoms suggestive of possible underlying thyroid disorder or prolactinoma, respectively.
Measures of genital congestion (e.g., vaginal photoplethysmography, laser Doppler imaging, genital magnetic resonance imaging, quantified sensory testing) are not used in diagnosis and instead are reserved for the research setting. Of note, women diagnosed with arousal disorder do not have reduced genital congestion when tested using photoplethysmography or genital MRI.[43][115] Validated questionnaires are available but are based on DSM-IV definitions of disorder and provide only a cursory picture of sexual functioning and should not be used in making diagnoses.
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