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Physical examination
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A general physical examination is highly recommended and can be directed by the medical history and its outcome However, a gynecologic examination is always recommended For women with genital arousal disorder, the information will be limited, as the genitalia are in the non-aroused state, but vaginal dystrophy suggesting estrogen de ciency or rarer conditions can be identi ed, as described below For women with subjective or combined arousal disorders, there most likely will be no abnormality Nevertheless a normal examination can be highly informative for the woman [5,26]
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Psychologic and relational history
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Cognitive and affective evaluation: Clarify her thoughts: is she feeling distracted, feeling tired, feeling sexually substandard, worried that the outcome would be negative, unsafe situation (pregnancy, STIs), feeling used, not being considered, unhappy about their sexual intimacy/practices Clarify her emotions: is there sadness, embarrassment, guilt, awkwardness, displeasure Relational evaluation:
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Sexual Arousal Disorders in Women The gynecologic examination should focus on: Inspection of vulvar anatomy Are there any changes or abnormalities For example, signs of in ammation, poor outcome of pelvic or perineal surgery, signs of lichen sclerosus or lichen planus, as well as involution or conglutination of the clitoris Skin colour and quality Is the skin thin and dry, or pink, supple and elastic Are there ssures, eczema, papules, pustules, vesicles, or ulcerations Does the vaginal mucosa appear estrogenized and moistened or does it appear atrophic with in ammation, ssures, erosions, and ulcers Does the speculum examination show signs of atrophy (eg petechiae or atrophy discharge) Palpation: Signs of myogenic or referred pain, or associated urogenital and rectal pain If the woman experiences pain, the pain map should be identi ed as described in 25 Pain is a strong re ex inhibitor of lubrication and therefore an important point to investigate Pelvic oor trophism, muscular tone and strength Scarring Sampling: Determination of pH, which gives indirect evidence of tissue estrogen level and related vaginal ecosystems Sampling and culture of discharge when infection is suspected
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rhea, and/or if bilateral breast milky discharge is present (not related to lactation) If the clinical history or objective ndings suggest hypothyroidism, TSH should be evaluated
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Investigational tests
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Vaginal plethysmography may be used to quantify the hemodynamic changes with female sexual arousal The everyday use of the method in clinical work is questionable This is due to the lack of a true baseline, the limited number of studies comparing women with disorders and functional women, and the dif culties in drawing conclusions on ndings from one measurement Furthermore, several studies have not found a correlation between the subjective report of arousal and the objective measured by the method [6,28] As such the method is at the present time mostly investigational Duplex doppler ultrasound can be used to measure changes in the clitoral, vaginal, labial, and urethral blood ow; for example, it can be measured before and after sexual stimulation Use of this method as a standard part of the evaluation is uncertain as larger studies still need to be conducted to identify cut-off values, normative data, correlation between disorder and objective parameters, as well as correlation between subjective and objective data In the future it may have a role in diagnosis, for example, in women with atherosclerotic changes leading to genital arousal problems [28 30]
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Laboratory tests
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Laboratory tests may be directed by relevant symptoms or ndings in the general medical assessment If low desire is co-morbid or suspected as the reason for low arousal (genital as well as subjective or combined), measuring testosterone status is recommended (including free testosterone) Plasma levels of estrogens can give information on the endocrine component of arousal disorder and the menopausal status (see also 27) However, plasma levels are not suf cient indicators of the experienced degree of vaginal dryness [27] Prolactin levels should be checked if there is comorbidity with marked oligomenorrhea or amenor-
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