A 46-year-old woman comes to the office due to sexual difficulties for the past year. The patient rarely thinks about sex anymore and frequently declines sex when her husband tries to initiate. She is attracted to her husband and worries that he assumes she is losing interest in him. Although vaginal lubrication is adequate during sex and the patient can reach orgasm, she finds that her mind wanders during the experience. She is unsure what is causing a decrease in her sex drive, although she notes that she received a promotion 3 months ago and has been working longer hours since then. The patient describes her marriage as stable and loving. She has a history of a depressive episode and currently takes bupropion. Physical examination and laboratory studies, including thyroid function tests, show no abnormalities. Which of the following is the most likely diagnosis?

Question

A 46-year-old woman comes to the office due to sexual difficulties for the past year.  The patient rarely thinks about sex anymore and frequently declines sex when her husband tries to initiate.  She is attracted to her husband and worries that he assumes she is losing interest in him.  Although vaginal lubrication is adequate during sex and the patient can reach orgasm, she finds that her mind wanders during the experience.  She is unsure what is causing a decrease in her sex drive, although she notes that she received a promotion 3 months ago and has been working longer hours since then.  The patient describes her marriage as stable and loving.  She has a history of a depressive episode and currently takes bupropion.  Physical examination and laboratory studies, including thyroid function tests, show no abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's lack of sexual desire is most consistent with female sexual interest/arousal disorder, a sexual disorder characterized by lack of, or significantly reduced, sexual interest and/or arousal. Diagnosis requires ruling out psychological, medical, and substance/medication-related causes of sexual dysfunction (eg, depression, diabetes, chronic alcohol or drug use) and relationship problems. The diagnosis of female sexual interest/arousal disorder encompasses symptoms of decreased interest, decreased arousal, or both. This patient primarily experiences decreased interest (ie, lack of sexual thoughts; reduced initiation of sexual activity or receptivity to a partner's attempts to initiate, but adequate lubrication/orgasm). Symptoms related to arousal may include decreased excitement/pleasure in response to mental and physical sexual cues and encounters. (Choice A) Although the patient mentions that her condition is worse since her promotion 3 months ago, there is evidence of a change in sexual functioning preceding this stressful event. (Choice B) Serotonergic antidepressants (eg, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors) are a common cause of medication-induced sexual dysfunction and can cause decreased libido as well as anorgasmia in women. This patient, however, is taking bupropion, a norepinephrine-dopamine reuptake inhibitor that does not affect serotonin and is unlikely to cause sexual side effects. (Choice C) Female orgasmic disorder is characterized by marked delay in, decreased frequency and intensity of, or absence of orgasms. (Choice E) Genitopelvic pain/penetration disorder involves recurrent difficulties with pain or fear of pain with vaginal intercourse or penetration attempts. (Choice F) Although declining levels of estrogen in peri- and post-menopausal women may be associated with decreased sexual interest in some patients, this is typically accompanied by decreased vaginal lubrication, which this woman does not describe. Educational objective: Female sexual interest/arousal disorder is characterized by lack of, or significantly reduced, sexual interest and/or arousal. Diagnosis requires ruling out psychological, medical, and substance/medication-related causes and relationship problems. __________ References: Hypoactive sexual desire disorder: International Society for the Study of Women's Sexual Health (ISSWSH) Expert Consensus Panel Review. (http://www.ncbi.nlm.nih.gov/pubmed/27916394)

A 46-Year-Old Woman Comes to the Office Due to Sexual