Female sexual interest, arousal and pain disorders — structured clinical viva

This is a biopsychosocial FSIAD + pain/GSM interface case with high likelihood of SSRI contribution and a partner request for a simplistic “female Viagra” fix. The viva tests nosology, mechanism models, medication literacy, process-of-care sequencing, and ethical couple framing without collusion.[3][6]

1. Classification. DSM-5-TR FSIAD merges interest/arousal features ≥6 months with distress; GPPPD covers penetration difficulty, pain, fear, and pelvic-floor tension. ICD-11 often separates desire, arousal, and pain-penetration disorders. Specifiers lifelong/acquired and generalised/situational. Distress is mandatory.[6]

2. Mechanisms. Basson responsive desire cycle; dual control (excitation vs inhibition).[1][7] SSRI serotonergic inhibition of desire/orgasm common.[3] Perimenopausal GSM drives dyspareunia and secondary desire loss.

3. Assessment. Phase-based sexual history; mood/trauma/IPV; medication review; FSFI domains for baseline; targeted labs; gynaecology/physio for pain/GSM — not pure psychologising.[2][6]

4. Stepped plan. Education; treat depression carefully; optimise/switch escitalopram; lubricants/local estrogen if GSM; sex therapy/CBT/couple work if safe. Consider bupropion strategies. Reserve specialised agents after foundation care.[3][6]

5. Flibanserin vs bremelanotide. Flibanserin 100 mg oral nightly, modest trial benefits, no alcohol, hypotension risk.[4] Bremelanotide 1.75 mg SC as needed, RECONNECT evidence, nausea common.[5] Neither is a universal “female Viagra”; availability varies by region.

6. Partner demand. Validate frustration; refuse coercive framing; patient-centred goals and consent; offer couple therapy only if non-abusive. Do not prescribe to satisfy partner demand alone.[6]