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Guideline No. 423: Female Genital Cosmetic Surgery and Procedures

      Abstract

      Objective

      To provide Canadian surgeons and other providers who offer female genital cosmetic surgery (FGCS) and procedures, and their referring practitioners, with evidence-based direction in response to increasing requests for, and availability of, vaginal and vulvar surgeries and procedures that fall outside the traditional realm of medically indicated reconstructions.

      Target Population

      Women of all ages seeking FGCS or procedures.

      Benefits, Harms, and Costs

      Health care providers play an important role in educating women about their anatomy and helping them appreciate individual variations. Most women requesting FGCS and procedures have normal genitalia, and up to 87% are reassured by counselling. At this time, due to lack of rigorous clinical or scientific evidence of short- and long-term efficacy and safety, FGCS and procedures for non-medical indications cannot be supported. FGCS and procedures are typically provided in the private sector, where costs are borne by the patient.

      Evidence

      Literature was retrieved through searches of MEDLINE, Scopus, and The Cochrane Library using appropriate controlled vocabulary and keywords. The selected search terms represented keywords for FGCS (labiaplasty, surgery, vaginal laser therapy, laser vaginal tightening, vaginal laser, vaginal rejuvenation, vaginal relaxation syndrome, hymenoplasty, vaginal cosmetic procedures) combined with female genital counselling, consent, satisfaction, follow-up, adolescent, and body dysmorphic or body dysmorphia. The search was restricted to publications after 2012 in order to update the literature since the previous guideline on this topic. Results were restricted to systematic reviews, randomized controlled trials, and observational studies. Studies were restricted to those involving humans, and no language restrictions were applied. The search was completed on May 20, 2020, and updated on November 10, 2020.

      Validation Methods

      The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

      Intended Audience

      Gynaecologists, primary care providers, surgeons performing FGCS and/or procedures.

      RECOMMENDATIONS

      • 1.
        Health providers should play an important role in educating women about their anatomy and helping them appreciate individual variations, including transitions through the reproductive life cycle (strong, low).
      • 2.
        For women who present with requests for vaginal cosmetic procedures, a complete medical, sexual, and gynaecological history must be obtained, and the absence of any major sexual or psychological dysfunction, including body dysmorphic disorder, should be ascertained. Any possibility of coercion or exploitation must also be ruled out (strong, high).
      • 3.
        There is insufficient evidence to support any female genital cosmetic surgery or procedure to improve sexual satisfaction and/or self-image. Physicians choosing to proceed with these cosmetic procedures should not promote these surgeries for the enhancement of sexual function or self-image (strong, low).
      • 4.
        Hymenoplasty is a surgical procedure that is not medically indicated. Counselling of the woman is paramount to provide both reassurance and accurate information that the procedure does not reliably result in the desired outcome of bleeding at first marital intercourse (strong, moderate).
      • 5.
        Laser is not recommended for genitourinary syndrome of menopause or cosmetic genital indications without further rigorous short- and long- term clinical research (strong, low).
      • 6.
        Counselling should be a priority for women requesting female genital cosmetic surgery and procedures that are not medically indicated. Topics should include normal variation and physiological changes over the lifespan, as well as the possibility of unintended consequences of cosmetic surgery to the genital area. The lack of both high-quality evidence and data regarding outcomes should also be discussed and considered as part of the informed decision-making process (strong, high).
      • 7.
        Caution should be used in advertising female genital cosmetic surgeries, to ensure such advertising is factual and not misleading (strong, high).
      • 8.
        Physicians who see adolescents requesting female genital cosmetic surgery require additional expertise in counselling adolescents (strong, low).
      • 9.
        Female genital cosmetic surgery must not be performed until genital maturity (strong, low).
      • 10.
        Surgery is not considered cosmetic if there is documented functional impairment, which may include structural, psychological, and/or anatomical concerns (strong, moderate).

      Keywords

      Abbreviations:

      BDD (body dysmorphic disorder), FGCS (female genital cosmetic surgery), GSM (genitourinary syndrome of menopause)
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