Female sexual interest/arousal disorder after SSRI treatment and comorbid dyspareunia (MEQ)

(i) Formulation. Working diagnoses: female sexual interest/arousal disorder (FSIAD) pattern with clinically significant distress; likely substantial SSRI-associated sexual dysfunction (timeline with sertraline); acquired genito-pelvic pain (entry dyspareunia) possibly multifactorial (secondary pain from dryness/tension, perimenopausal tissue change, anxiety). Residual MDD. Psychosocial: partner criticism/coercive tone risk, relationship threat. Differentials: pure primary HSDD independent of drug; hyperprolactinaemia if other agents; thyroid disease; GSM/early atrophy; trauma-related avoidance; relationship-only problem without individual criteria (does not fit here given personal distress); infection/dermatosis needing gynaecology.^[3][4][7]

(ii) Assessment. Confidential sexual history (lifelong vs acquired, generalised vs situational, desire/arousal/orgasm/pain, distress). MSE and suicide/relationship safety screen. Trauma, substances, contraception/fertility. Full medication review. FSFI for domains and baseline.^[2] Targeted labs as indicated (TSH, prolactin if suggested, metabolic context). Gynaecology/pelvic floor referral for pain and perimenopausal symptoms; do not assume “psychogenic only.” Use Basson responsive-desire language to reduce shame.^[1][7]

(iii) Stepped management. Psychoeducation; stop framing her as “broken.” Optimise depression and address sertraline with shared decision: careful dose reduction if safe, switch to lower sexual-burden agent, or adjunct bupropion SR 150 mg orally once daily titrating toward 150 mg orally twice daily if tolerated (exclude seizure risk, eating-disorder history).^[3][4][5] Parallel sex therapy/CBT, couple sessions if safe, lubricants/moisturisers, consider local estrogen if GSM confirmed. If residual premenopausal HSDD after optimisation, discuss modest-benefit options such as flibanserin 100 mg orally at bedtime with no alcohol (availability regional) rather than as first step.^[6][7] Pain pathway: physio and graded approaches if tension/vaginismus features emerge; avoid forced intercourse.^[8]

(iv) Relationship/safety. Name the partner’s “broken” language as harmful; assess coercion/IPV. Prioritise consent. Offer couple work only if non-coercive. Safety-net for mood deterioration during antidepressant changes.^[7]

(v) Prognosis/disposition. Many medication-related cases improve with regimen change; residual symptoms common. Outpatient psychiatry + sex therapy ± gynaecology/physio; review 4–8 weeks after medication changes; escalate if risk or refractory pain.^[7]