CASE INFORMATION
Case ID: SFS-001
Case Name: Sarah Thompson
Age: 35 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: X24 (Sexual function symptom/complaint, female)
COMPETENCY OUTCOMES
| Competency Domain | Competency Element |
|---|---|
| 1. Communication and Consultation Skills | 1.1 Creates a safe, non-judgmental space for discussion 1.2 Uses open-ended questions to explore concerns 1.3 Provides clear, empathetic explanations of diagnosis and management |
| 2. Clinical Information Gathering and Interpretation | 2.1 Takes a thorough sexual and reproductive history 2.2 Identifies psychological, physical, and relational factors contributing to the concern 2.3 Performs appropriate physical and mental health assessments |
| 3. Diagnosis, Decision-Making and Reasoning | 3.1 Differentiates between primary and secondary sexual dysfunction 3.2 Considers hormonal, psychological, and relational contributors 3.3 Orders relevant investigations if indicated |
| 4. Clinical Management and Therapeutic Reasoning | 4.1 Provides patient-centred, evidence-based management 4.2 Refers appropriately for psychological or specialist support 4.3 Considers pharmacological and non-pharmacological interventions |
| 5. Preventive and Population Health | 5.1 Screens for underlying conditions such as depression, menopause, or medication side effects 5.2 Provides sexual health education and relationship counselling options |
| 6. Professionalism | 6.1 Demonstrates a respectful, non-judgmental approach to sensitive issues |
| 7. General Practice Systems and Regulatory Requirements | 7.1 Ensures documentation is sensitive yet complete 7.2 Refers appropriately within ethical and legal guidelines |
| 9. Managing Uncertainty | 9.1 Recognises when a multidisciplinary approach is required |
| 10. Identifying and Managing the Patient with Significant Illness | 10.1 Identifies serious mental health conditions associated with sexual dysfunction |
CASE FEATURES
- Female sexual dysfunction presenting with low libido and discomfort.
- Complex interplay of psychological, relational, hormonal, and medical factors.
- Sensitive topic requiring empathetic and open communication.
- Consideration of potential underlying conditions (depression, menopause, relationship concerns, medications).
CANDIDATE INFORMATION
INSTRUCTIONS
Review the following patient record summary and scenario.
Your examiner will ask you a series of questions based on this information.
You have 15 minutes to complete this case.
The time for each question will be managed by the examiner.
The time allocation for each question is roughly as follows:
- Question 1 – 3 minutes
- Question 2 – 3 minutes
- Question 3 – 3 minutes
- Question 4 – 3 minutes
- Question 5 – 3 minutes
PATIENT RECORD SUMMARY
Patient Details
Name: Sarah Thompson
Age: 35 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- Nil known
Medications
- Sertraline 50 mg daily (for anxiety, started 6 months ago)
- Oral contraceptive pill (ethinylestradiol/levonorgestrel)
Past History
- Generalised Anxiety Disorder (GAD), well-controlled
- No history of pelvic infections or sexually transmitted infections (STIs)
- No significant medical conditions
Social History
- Married for 10 years, two children (ages 6 and 4)
- Employed part-time as a teacher
- No smoking or illicit drug use
- Alcohol: 2-3 standard drinks per week
- Reports increased stress due to work-life balance issues
Family History
- No family history of endocrine disorders or sexual dysfunction
- Mother had early menopause at 42 years
Vaccination and Preventative Activities
- Cervical screening up to date (normal results 1 year ago)
- No history of sexual assault or trauma reported
SCENARIO
Sarah, a 35-year-old married woman, presents to her GP with concerns about low libido and discomfort during intercourse over the past six months. She describes a lack of desire for sex, which is causing tension in her marriage. She also experiences vaginal dryness and discomfort during penetration.
She notes that her sexual function was normal before but has declined since starting sertraline. She also reports increased fatigue and stress due to balancing work and family life. Her husband is supportive but has expressed frustration about their reduced intimacy.
She is worried that something is “wrong” with her and is concerned about the future of her relationship. She asks, “Is this normal? Is there anything I can do?”
Your role is to explore Sarah’s concerns sensitively, identify possible contributing factors, develop a management plan, and offer appropriate referrals if necessary.
EXAMINATION FINDINGS
General Appearance: Well-groomed, slightly anxious but engaged in conversation
Vital Signs: Normal
Abdominal Examination: Soft, non-tender
Pelvic Examination (if performed and consented): Mild vaginal dryness, no signs of infection or atrophy
Mental Health Screening: Mild symptoms of anxiety, PHQ-9 score 5 (minimal depression)
Relationship Context: Supportive partner, no concerns about abuse or coercion
EXAMINER ONLY INFORMATION
QUESTIONS
Q1. How would you explore Sarah’s concerns about sexual dysfunction?
- Prompt: What key aspects of history would you focus on?
- Prompt: How would you approach this discussion sensitively?
Q2. What are the possible causes of Sarah’s symptoms, and how would you assess them?
- Prompt: How would you differentiate between physiological and psychological causes?
- Prompt: What investigations, if any, would be appropriate?
Q3. What management options would you discuss with Sarah?
- Prompt: What lifestyle, psychological, and medical interventions could be helpful?
- Prompt: When would referral to a specialist be indicated?
Q4. How would you counsel Sarah regarding her concerns about the impact on her marriage?
- Prompt: What communication strategies might help her and her partner?
- Prompt: What resources or support services could be beneficial?
Q5. What preventive strategies can be discussed to improve Sarah’s sexual health and well-being?
- Prompt: How can you address long-term sexual health and relationship well-being?
- Prompt: What steps can Sarah take to manage stress and hormonal changes?
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Q1: How would you explore Sarah’s concerns about sexual dysfunction?
A structured and empathetic approach is essential in discussing sexual dysfunction. It is important to establish rapport, normalise the discussion, and use open-ended questions.
1. Establish a Safe and Supportive Environment
- Use open-ended questions: “Can you tell me more about your concerns?”
- Reassure: “This is a common issue, and we can work through it together.”
- Use normalising language: “Many women experience changes in libido at different stages of life.”
2. Comprehensive History-Taking
- Nature of the concern: Loss of desire, arousal issues, discomfort.
- Onset and duration: Gradual vs sudden, primary vs secondary dysfunction.
- Psychosocial factors: Relationship dynamics, stress, mental health.
- Medical factors: Medications (sertraline, OCP), chronic illness.
- Hormonal considerations: Menstrual cycle, perimenopause signs.
- Lifestyle factors: Exercise, alcohol, smoking.
- History of sexual trauma (if comfortable discussing).
Conclusion: A non-judgmental and structured history is essential in identifying contributing factors.
Q2: What are the possible causes of Sarah’s symptoms, and how would you assess them?
1. Potential Causes
- Psychological: Stress, anxiety, relationship issues.
- Medication-related: SSRI (sertraline) is known to cause low libido.
- Hormonal: OCP use, perimenopause.
- Medical: Hypothyroidism, diabetes.
- Pain-related: Vaginal dryness, pelvic floor dysfunction.
2. Assessment
- Screen for mental health concerns (GAD-7, PHQ-9).
- Physical exam: Pelvic exam if indicated.
- Blood tests (if warranted): Thyroid function, iron studies, hormones.
- Medication review: Discuss alternative antidepressants.
Conclusion: Sarah’s symptoms likely have a multifactorial cause, including SSRI effects, stress, and hormonal changes.
Q3: What management options would you discuss with Sarah?
1. Lifestyle and Behavioural Strategies
- Regular exercise, stress reduction.
- Mindfulness and couple intimacy exercises.
2. Psychological Support
- Cognitive-behavioural therapy (CBT) for anxiety.
- Sex therapist referral if needed.
3. Medication Adjustments
- Consider alternative antidepressants (e.g., mirtazapine, bupropion).
- Vaginal moisturisers/lubricants.
4. Hormonal Considerations
- OCP adjustment or alternative contraception.
- Consider hormonal therapy if perimenopausal signs present.
Conclusion: A multidisciplinary approach is required, including medication review, therapy, and relationship counselling.
Q4: How would you counsel Sarah regarding her concerns about the impact on her marriage?
1. Address Emotional Concerns
- Reassure: “It is normal for relationships to evolve.”
- Encourage open communication with her partner.
2. Relationship Strategies
- Encourage couple intimacy beyond intercourse.
- Provide resources for couple counselling.
3. Set Realistic Expectations
- Address guilt and self-blame.
- Emphasise that libido changes are manageable.
Conclusion: Helping Sarah navigate relationship dynamics is essential in reducing anxiety and improving intimacy.
Q5: What preventive strategies can be discussed to improve Sarah’s sexual health and well-being?
1. Address Modifiable Factors
- Regular physical activity improves libido.
- Balanced diet supports hormonal health.
2. Long-Term Mental and Relationship Well-being
- Mindfulness and stress reduction.
- Encourage regular communication with her partner.
3. Medication and Hormonal Considerations
- Regular medication reviews for potential sexual side effects.
- Monitor for perimenopause changes.
Conclusion: A proactive approach to physical, emotional, and sexual health helps prevent recurrence.
SUMMARY OF A COMPETENT ANSWER
- Creates a safe and non-judgmental environment.
- Takes a structured and comprehensive sexual health history.
- Identifies SSRI-related libido changes and other contributing factors.
- Develops a multidisciplinary, patient-centred management plan.
- Provides effective counselling on relationships and sexual well-being.
PITFALLS
- Failing to create a comfortable and open discussion space.
- Overlooking medication side effects, particularly SSRIs.
- Not considering relationship dynamics and emotional factors.
- Neglecting to offer non-pharmacological management options.
- Overinvestigating without clear indications.
REFERENCES
MARKING
Each competency area is on the following scale from 0 to 3.
☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD