see attachment
Table 1: Terminology Definitions
Table 2: Female Sexual Dysfunction
Term Definition
Sexualit
y
A broad concept encompassing sexual feelings, thoughts, attractions,
preferences, and behaviors across a lifespan.
Sexual
health
A state of physical, emotional, mental, and social well-being in relation to
sexuality; not merely the absence of disease or dysfunction (WHO, 2022).
Sexual
identity
How a person views themselves in terms of their sexual orientation and
sexual expression.
Sexual
orientat
ion
A person’s pattern of emotional, romantic, or sexual attraction to others
(e.g., heterosexual, homosexual, bisexual, asexual).
Sexual
agency
The capacity of individuals to make informed, autonomous decisions
regarding their sexual activity and expression.
Sex Biological characteristics assigned at birth based on anatomy and
chromosomes (e.g., male, female, intersex).
Gender
Identity
A person’s deeply held sense of their gender, which may or may not align
with their sex assigned at birth.
Transge
nder
A person whose gender identity differs from the sex they were assigned at
birth.
Gender
dyspho
ria
Psychological distress resulting from a mismatch between one’s gender
identity and assigned sex at birth.
Cisgen
der
A person whose gender identity aligns with the sex assigned to them at
birth.
Transm
ale A person assigned female at birth who identifies and lives as male.
Transfe
male A person assigned male at birth who identifies and lives as female.
Table 3: Vulvodynia and Vaginismus
SOAP Note
Patient Name: Gayle
Age: 25
Gender: Female
Chief Complaint: “I’m here for my first Pap smear, but I’ve never been able to tolerate it
before.”
Category Examples
5 Medical
(Physical)
Causes
Diabetes mellitus, hypothyroidism, menopause (estrogen
deficiency), chronic pelvic pain, multiple sclerosis
5 Medication-
Induced Causes
SSRIs (e.g., fluoxetine), antihypertensives (e.g., beta-blockers),
antipsychotics, opioids, hormonal contraceptives
5 Psychological
Causes
Depression, anxiety, history of trauma or abuse, low self-esteem,
relationship conflict
Management
Plans
Pharmacologic: 1) Flibanserin (Addyi) for HSDD, 2) Vaginal
estrogen for dryness and pain.
Non-pharmacologic: 1) Pelvic floor physical therapy, 2) Sex
therapy or cognitive behavioral therapy (CBT)
Item Answer
Define
Vulvodynia
Chronic vulvar pain without identifiable cause, lasting at least 3 months,
often described as burning, stinging, irritation, or rawness.
Define
Vaginismus
Involuntary contraction of pelvic floor muscles that interferes with
vaginal penetration, often associated with fear, anxiety, or past trauma.
Difference
Between
the Two
Vulvodynia is primarily pain-based, occurring without muscle spasm;
vaginismus is characterized by involuntary muscle tightening that
prevents penetration.
Treatment
Options
Vulvodynia: Topical lidocaine, low-dose tricyclic antidepressants, pelvic
floor PT, CBT.
Vaginismus: Vaginal dilator therapy, pelvic floor PT, sex therapy,
anxiolytics if anxiety is a factor.
S: Subjective
HPI:
Gayle is a 25-year-old woman presenting for her first Pap smear. She attempted a Pap smear once
previously but could not tolerate speculum insertion due to pain at the vaginal introitus. She
reports an ongoing history of pain with any attempts at vaginal penetration, including tampon use
and intercourse. She first noticed pain at age 19 when she tried to use tampons. At 21, she
attempted vaginal intercourse but experienced significant introitus pain that made penetration
impossible. She has not had successful vaginal intercourse to date. The pain is described as sharp
and located right at the opening of the vagina. There is no associated itching, discharge, or
burning. She expresses high levels of anxiety surrounding pelvic exams and is tearful when
discussing the procedure.
Menstrual History:
• Menarche at age 13
• Regular monthly menses, lasting 5-6 days
• Does not use tampons due to pain on insertion
• No reported dysmenorrhea or menorrhagia
Sexual History:
• Never able to complete vaginal intercourse due to pain
• One prior relationship ended due to sexual difficulties
• Denies history of sexual abuse
• No known history of sexually transmitted infections (STIs)
• Not currently sexually active
Obstetric History:
• G0P0
Gynecologic History:
• No prior Pap smears completed
• No history of gynecologic surgeries or procedures
• No vaginal infections or abnormalities noted previously
Psychosocial:
• College graduate, employed full-time
• Lives alone, strong support system
• Expresses guilt, shame, and embarrassment about inability to tolerate vaginal penetration
• High anxiety surrounding medical exams
Medications: None
Allergies: NKDA
PMH: Unremarkable
PSH: None
FH: Non-contributory
SH: Denies smoking, alcohol, or drug use
O: Objective
General: Alert, cooperative, visibly anxious, tearful during interview
Vital Signs: WNL
HEENT: Normal
Neck: Supple, no lymphadenopathy
Cardiovascular/Respiratory/Abdomen: Unremarkable
External Genitalia Exam:
• External exam deferred due to patient anxiety and distress
• No vulvar abnormalities noted on brief inspection
• No visible lesions or discharge
A: Assessment
Primary Diagnosis:
• Genito-pelvic pain/penetration disorder (GPPPD) – ICD-10: F52.6
o Formerly classified under vaginismus and dyspareunia
o Characterized by persistent or recurrent difficulties with vaginal penetration, associated with
pain, fear/anxiety, and pelvic floor muscle tension
Differential Diagnoses to Consider:
• Vulvodynia (N94.819)
• Pelvic floor muscle dysfunction
• History of trauma (denied by patient)
• Dermatoses or congenital anomalies (if later suspected)
P: Plan
Diagnostics:
• Pelvic exam deferred today due to patient distress and need for further evaluation and trust-
building
• Consider use of pelvic floor physical therapy consult prior to attempting Pap
• No Pap smear today; discuss alternatives if clinically appropriate (e.g., self-sampling for
HPV in the future, if evidence-based and accessible)
Referrals:
• Pelvic floor physical therapy – for evaluation and treatment of suspected pelvic floor
dysfunction
• Sex therapist or psychologist – experienced in sexual health and genito-pelvic pain
disorders
• Consider referral to gynecologist specializing in sexual dysfunction or vulvovaginal
disorders if needed
Treatment/Education:
• Reassured patient that she is not alone and that this is a common condition
• Validated her emotions and normalized her anxiety
• Discussed that Pap smears can be deferred in special cases and alternative methods may be
considered
• Introduced the idea of using vaginal trainers or dilators under professional guidance
• Educated on the nature of genito-pelvic pain/penetration disorder and the importance of a
multidisciplinary approach
• Emphasized that the goal is comfort, not rushing into painful procedures
Follow-Up:
• Schedule follow-up in 4–6 weeks after initial therapy sessions for re-evaluation and to plan
gradual introduction of pelvic exam if appropriate
• Patient encouraged to return sooner for any concerns or questions
- Table 1: Terminology Definitions
- Table 2: Female Sexual Dysfunction
- Table 3: Vulvodynia and Vaginismus
- S: Subjective
- O: Objective
- A: Assessment
- P: Plan
