Chapter 27: Sexual Difficulties Flashcards
You are a trainee intern in a general practice seeing Elsie, a 22 year old Pākehā woman who is concerned because she has not felt like having sex with her boyfriend for the last six months. It is now impacting their relationship. They have been together for 2 years. She cannot think of a reason this might be the case. Since menarche, aged 12, she has had monthly painless periods until she started the oral contraceptive pill 3 years ago which she has always taken continuously. She has been amenorrhoeic on the pill. Elsie takes no other regular medications, is generally fit and well, and enjoys her work as a swimming instructor. From the following options, what is the MOST APPROPRIATE question to ask next?
Have you had any other sexual partners?
Have you been tested for STIs in this relationship?
Has sex with your current partner previously been pleasurable?
Have you experienced childhood sexual abuse?
Have you considered changing contraception to see if the pill is causing the problem?
Has sex with your current partner previously been pleasurable?
You are a trainee intern in the gynaecology clinic with Ayadi, a 36 year old Somali woman who presents with her 35 year old husband. They have been married for 2 years and would like to have a baby. However, she underwent female genital mutilation (FGM) as a child in Somalia that involved sewing the labia together to make the vaginal opening smaller (infibulation). Because of this, she finds vaginal penetration very painful and this is limiting her ability to have sex. She also finds urinating difficult. Ayadi and her husband would like to enjoy sex together. Ayadi consents to you examining her - under the supervision of your consultant. On examination the labia majora are fused anteriorly creating a very small introitus. She cannot tolerate a one finger digital examination. The clitoris is intact. Which of the following is the BEST management option for her to achieve a pregnancy?
Teach her how to use vaginal dilators to enable better penetration
Encourage the use of lubricant to make sex less painful
Refer to fertility service for insemination using husband’s sperm
Refer to fertility service for IVF
Refer for counselling for FGM related trauma
Arrange surgery to separate the labia
Arrange surgery to separate the labia
You are a trainee intern in a gynaecology clinic with Abbie, a 21 yr old para 1 Pākehā woman who is concerned that 6 months after the birth of her daughter she is always finding sex painful. The pain is felt in one spot on the left side just within the vulva. Abbie and her regular male partner are using condoms for contraception with a vaginal lubricant. She experienced a second-degree vaginal-wall tear at the time of delivery which was repaired. She is otherwise well and not taking any regular medications. She stopped breastfeeding after 4 months and has since had two periods. On vaginal examination, the tear has healed but there is an area of smooth scar tissue on the left lateral wall of the vagina which is painful on palpation. She is able to voluntarily contract and relax the pelvic floor muscles without pain. Of the following possible management options, which is the best advice?
Encourage use of vaginal dilators
Refer for Botox therapy as likely neuroma
Take analgesia before sex
Arrange scar revision and repair
Refer to a specialist women’s health physiotherapy for scar massage
Advise pelvic floor muscle training to increase pelvic floor tone
Arrange prescription of vaginal oestrogen cream to increase tissue elasticity
Refer to a specialist women’s health physiotherapy for scar massage
You are a trainee intern in general practice with Nisha, a 21 year old nulliparous Indian woman medical student who describes increasing fear of sex since her arranged marriage four months ago. They are trying for a baby and her husband has become increasingly demanding for sex, sometimes twice daily, which she now fears. She feels pressured to have sex when she doesn’t want to. Sex has become painful and “dry”. Nisha has regular painless periods every four weeks. What is the MOST IMPORTANT thing to do for Nisha?
Provide information about pregnancy care in NZ
Advise her to communicate with her husband about the female sexual response
Arrange prescription of a lubricant
Inform her about the normal sexual response, and vaginal lubrication
Advise her that in some cultures, there are discrepancies between genders about sexual practices and expectations
Assess her personal safety
Assess her personal safety
You are a trainee intern at a gynaecology outpatient clinic with Rachel (they/them), a 52 year old para 3 Pākehā person who is attending for an annual check-up post total hysterectomy with bilateral salpingo-oophorectomy 2 years ago for ovarian cancer. Receiving the cancer diagnosis and going through the treatment was a traumatic time for them as their prognosis had initially been relatively poor. However, they had an excellent recovery with a very good outcome. Their main issue now is that they have not had sex since the diagnosis and has no desire saying “I just don’t want to be touched”. They would like to start having a fulfilling sexual relationship again with their husband. From the following options, what would be the FIRST thing that Rachel could do to achieve this?
Come back to see you with their husband so that you can talk through the issues together
Use vaginal oestrogen cream as they will likely be atrophic due to removal of their ovaries
Avoid penetrative sex and focus instead on other pleasurable activities such as oral sex.
Seek specialist counselling to help address the trauma experienced during their cancer diagnosis and treatment
Start an antidepressant for post-traumatic stress associated with the cancer
Seek specialist counselling to help address the trauma experienced during their cancer diagnosis and treatment
You are a trainee intern in general practice with Penina, a 28 year old G0P0 Samoan woman who presents feeling tired and depressed. She married her 46 year old former boss 6 months ago after a 5 year affair. He divorced his former wife 2 years ago. During their affair he had no sexual problems. However since their wedding he has had no desire for sex and when it does occur, he often ejaculates prematurely or has erectile difficulties. Penina feels that they don’t communicate as openly as they used to. Which of the following options is the MOST LIKELY initial management?
Check for psychological and/or physical safety concerns
Suggest that her husband no longer loves her
Prescribe an anti-depressant
Suggest her husband is referred to check out his sexual concerns
Encourage communication with each other about their relationship, including their sexual relationship
Improving her knowledge about erotic technique
Encourage communication with each other about their relationship, including their sexual relationship
You are a trainee intern in general practice with Rosie (she/her), a 20 year old nulliparous Pākehā woman who is concerned that she does not achieve orgasm with penetrative sex, but can reach orgasm by masturbation. She has been with her boyfriend, also aged 20, for six months and neither of them had had sex before this relationship. She states that her boyfriend has no difficulty with erection or ejaculation. She does enjoy the intimacy that comes with sex but feels shy with her partner and won’t let him touch her “down there”. She is concerned that there is something wrong with her because she doesn’t orgasm with penetrative sex. From the following options, what is MOST APPROPRIATE to address with Rosie next?
Ask about relationship safety and any history of sexual abuse
Most women require clitoral stimulation during sex to reach orgasm
She needs to learn how to relax when having sex
Encourage mutual masturbation to increase sexual confidence
Make sure she is using effective contraception
Most women require clitoral stimulation during sex to reach orgasm
You are a trainee intern in general practice with Ashley, a 26 year old Pākehā woman who wishes to conceive. However, she has never had penetrative sex in 2 years of marriage because she believes her vagina is too small for her husband’s penis. They enjoy mutual stimulation and masturbation about twice per week, and she achieves orgasm with clitoral stimulation on about half these occasions. He always ejaculates. Neither has had a previous sexual partner because of their religious beliefs. Ashley uses sanitary pads, and has never attempted to use tampons. She has never had a cervical screening test. Which of the following options should you recommend?
Speculum examination with cervical screening test under general anaesthesia
Use vaginal dilators
Refer to a physiotherapist for deep muscle relaxation
Assessment of her external genitalia, introitus, and hymen area
Desensitisation by digital insertion by him
De-sensitisation by self-digital insertion
Assessment of her external genitalia, introitus, and hymen area
You are a trainee intern at a gynaecology clinic seeing Solosolo, a 26 year old para 1 Samoan woman for her post-natal check. She had a caesarean section six weeks ago due to fetal distress. She is fully breast feeding. Solosolo has not had any periods, and is using condoms for contraception. She had sex again with her male partner from two weeks after the birth. Initially she felt “dry” but since then sex has become increasingly painful. She now has no wish to have sex. Examination is normal, apart from atrophic vaginal epithelium. From the following options, what is the MOST LIKELY management?
Marital relationship counselling
Referral to a physiotherapist for biofeedback
Desensitisation of the vagina by self insertion exercises
A vaginal lubricant
Psychological counselling about her loss of libido
Cease breast feeding
A vaginal lubricant
due to Breastfeeding
You are a trainee intern at a general practice seeing Alice, a 62 year old Pākehā woman who is experiencing pain with sex. Her partner died 10 years ago and she has just recently gotten into a relationship with a new woman. She finds digital vaginal penetration very dry and painful, even when using a vaginal lubricant. Her last menstrual period was 12 years ago and she has not had any vaginal bleeding since then. Alice is in good health and has no history of any previous gynaecological problems. Her last cervical smear was last year and she has always had normal smears. From the following, what is the MOST LIKELY management option?
She change the vaginal lubricant that she is using
You advise only to engage in clitoral stimulation with her partner
You advise use of vaginal dilators
You suggest psychosexual counselling
You take vaginal swabs
You prescribe vaginal oestrogen cream
You prescribe vaginal oestrogen cream
post-menopausal and sexually inactive 10 yrs
