Sexual dysfunction and dyspareunia — structured SAQ (15 marks)

(a) Classification and symptom location — 4 marks

• One mark: state the four practical symptom domains: desire, arousal, orgasmic and genito-pelvic pain/penetration disorders. ^[1]
• One mark: locate her dominant problem as superficial/entry dyspareunia, with clinical GSM features.
• One mark: identify reduced desire as possibly secondary to pain, dryness and menopause; do not label primary HSDD before assessing contributors.
• One mark: record acquired/generalized or situational pattern and personal distress/impairment; a partner mismatch alone is not a disorder. ^[1]

(b) Biopsychosocial assessment and examination — 4 marks

• History, one mark: onset and timeline; pain site, trigger, severity, after-pain and cyclicity; desire/arousal/orgasm; sexual practices and contraception/pregnancy intentions.
• Body, one mark: menopause and lactation status, childbirth/perineal trauma, pelvic surgery, infection symptoms, endometriosis symptoms, chronic pain, medicines, mood, sleep and medical disease.
• Context and safety, one mark: relationship and communication, body image, trauma, coercion/intimate partner violence; ask privately and use permission-based language.
• Examination, one mark: consent and chaperone; external inspection, cotton-bud mapping, single-digit pelvic-floor tone/tenderness, speculum and bimanual examination only when indicated and accepted. ^[4]

(c) Stepwise management — 5 marks

• One mark: validate, explain GSM and pain–guarding, stop irritants, advise non-painful intimacy and generous lubricant during activity; regular moisturiser for baseline dryness. ^[2][3]
• One mark: use PLISSIT: permission, limited information, specific suggestions and intensive therapy referral when required.
• One mark: if symptoms persist and no contraindication, offer low-dose vaginal oestrogen according to local Australian product information; review response and ongoing need. ^[3]
• One mark: refer for pelvic-floor physiotherapy focused on relaxation/down-training and for CBT or psychosexual therapy addressing fear, avoidance, mood, intimacy and communication. ^[4]
• One mark: review medication and medical contributors; do not use systemic testosterone unless a specialist assessment confirms postmenopausal HSDD after other contributors are addressed and monitoring is arranged. ^[1]

(d) Safety-net and referral — 2 marks

• One mark: urgent reassessment for postcoital or postmenopausal bleeding, lesion, discharge/fever, mass, urinary retention or escalating deep pain.
• One mark: refer to vulval pain, sexual-health, menopause, endometriosis, pelvic-floor or oncology services according to findings; involve oncology in persistent GSM after breast cancer. ^[3]

Common errors that lose marks

• Calling all low desire “HSDD” without assessing pain, mood, medication and relationship context.
• Treating superficial pain as endometriosis without examining the vulva and vestibule.
• Performing an intimate examination without consent, explanation or a stop signal.
• Recommending pelvic-floor strengthening when the muscles are tender and overactive.
• Giving a blanket vaginal-oestrogen prescription without checking unexplained bleeding and breast-cancer context.

Examiner notes

This case tests distinction between symptom domains, non-linear sexual response, a patient-led biopsychosocial assessment, PLISSIT and safe GSM management. Credit equivalent clear language. Do not require a specific questionnaire. The candidate should explicitly state that the patient's goal and distress guide treatment.