This document discusses controversies in aesthetic gynecology procedures. It begins by defining aesthetic gynecology as procedures that alter female genital appearance or structure for non-medical reasons. The document then outlines the increasing popularity of these procedures in recent years. It notes both opponents and proponents of these procedures and their differing views on issues like patient autonomy and lack of evidence. The document concludes by summarizing various medical organizations' ethical guidelines, which state that the safety and effectiveness of many aesthetic gynecology procedures have not been established and caution is warranted.

1. CONTROVERSIES IN
AESTHETIC GYNECOLOGY
Prof. Aboubakr Elnashar
Benha university Hospital, Egypt
ABOUBAKR ELNASHAR

2. ABOUBAKR ELNASHAR
CONTENTS
 INTRODUCTION
1. DEFINITION
2. STATISTICS
3. CAUSES OF INCREASED DEMAND FOR FGCS
4. INDICATIONS
5. PROCEDURES
6. OUTCOMES
 CONTROVERSY
1. OPPONENTS
2. PROPONENTS
3. ETHICAL GUIDELINES

3.  Aesthetic Gynecology: Aes G
Alteration of anatomy
vaginal or labial: for
Aesthetic reasons (artistic& visual) or
Treatment of normal changes that occur throughout
the life span.
Cosmetic procedures
Non medically indicated:
Change the structure& appearance of
healthy vulva or vagina.
ABOUBAKR ELNASHAR

4. FGM FGCS
1. Practice Condemned Requested
2. Conducted on Girls Adult women
3. Consent Against Mandatory
4. Objective False belief to
control female
sexuality
Improve their
appearance&
sexuality.
ABOUBAKR ELNASHAR

5. 2013:
 In US:
 Labiaplasty was reported to be the 4th most
common cosmetic surgical procedure, rising by
44%.
 Following liposuction, breast augmentation, and rhinoplasty,
 Australia:
 3-fold increase in labiaplasties performed between
2003 and 2013
 UK:
 5-fold increase in these surgeries during the same period.
ABOUBAKR ELNASHAR

6. CAUSES OF INCREASED DEMAND FOR AES G
1 Perception of ‘normal’ Vs ‘desirable’
‫والمرغوب‬ ‫طبيعي‬ ‫هو‬ ‫لما‬ ‫اﻻدراك‬
ABOUBAKR ELNASHAR

7. 4. Lack of anatomy education throughout life
5. In some countries:
 Decreased cost & shame
 Increased ease of access to Aes G
ABOUBAKR ELNASHAR

8.  Comparing 2017 to 2016 data.
 11% decrease in surgical procedures
 Increase in laser/nonsurgical interventions
(American Society for Aesthetic Plastic Surgery, 2018)
 This raised the question
 Whether surgical procedures is a passing
trend? (Placik et al, 2019)

9. INDICATIONS: Why do women seek Aes G?
1. Aesthetic reasons
 To reduce dissatisfaction associated with actual or
perceived abnormality of genital anatomy
2. Functional reasons:
 To reduce
 pain or interference with SI
 discomfort when exercising or wearing tight clothing
 To improve s. function or s. enhancement.
3. Psychological reasons: To address
 embarrassment, poor self-esteem, anxiety
 inhibition in relationships, or to be more 'normal'
ABOUBAKR ELNASHAR

10. PERFORMED BY
 It is most commonly performed by:
1. Gynaecologists: 50%
2. Plastic surgeons: 30% (Placik et al, 2019)
3. GPs or non-specialist surgeons
(including dermatologists), with additional training in
cosmetic procedures
4. Urologists
ABOUBAKR ELNASHAR

11. PROCEDURES
I. Vulvoplasty: Augmentation or more frequently,
reduction of the external female genitalia
 Labiaplasty: Augmentation or reduction of the labia
minora, or less commonly the labia majora
 Hymenoplasty or ‘revirgination: Restoration of the
intact hymen
 Clitoral hoodoplasty: Reduction of the clitoral hood
to expose the underlying clitoris
 Vulvar lipoplasty: Removal of fat from mons pubis.
ABOUBAKR ELNASHAR

12. II. Vaginoplasty: Alteration of the internal female genitalia
 Surgical vaginal tightening
 Perineoplasty: Restoration of perineal length
 Laser Vaginal Rejuvenation: vaginal tightening
using laser therapy
 G-spot augmentation or amplifcation ('G-shot'®)
Autologous fat, collagen, or various filler injections
into a predetermined G-spot'
 Orgasm Shot ('O-Shot’®): Patient’s own blood
products are injected into the clitoris & upper vaginal wall
ABOUBAKR ELNASHAR

13.  Surgical:
 Non-surgical
1. Energy-Based Procedures: use of
 Lasers or
 Radiofrequency (RF) energy
 US
2. Injection
 Botox
 PRP
 Filler
 Autologs fat
 Collagen ABOUBAKR ELNASHAR

14.  Wilkie et al, 2018
ABOUBAKR ELNASHAR

15. ABOUBAKR ELNASHAR
Aesthetic
Genital
Surgery
OPPONENTS

16. Opponents Of Aes G
1. There is a wide range of normal genitalia:
surgery& rejuvenation procedures unnecessary
(Lloyd et al, 2005)
2. There are numerous marketing claims stating that
these procedures
 enhance sexual satisfaction
 treat both aesthetic& functional issues:
patients request surgery for the wrong
reasons (Braun, 2010)
ABOUBAKR ELNASHAR

17. 3. These procedures are lucrative
patients pay out of cost for these procedures,
raising concerns about direct patient cost& provider
conflict (Lglesia, 2012)
ABOUBAKR ELNASHAR

18. 4. A number of patients seeking Aes G are
 at risk of body dysmorphic disorder
(Recurrent obsessive ideas that a particular aspect of
their appearance is severely faulty)
should be treated, rather than proceeding with
Aes G (Higgins, Wysong, 2018)
ABOUBAKR ELNASHAR

19. 5. The performance of some procedures can be
accepted in some instances
Others:
 No medical justification or biological
acceptability.
 Unethical (Pedro et al, 2018)
ABOUBAKR ELNASHAR

20. 6. Protrusion of the labia minora’
 not a medical problem, but a cultural one.
 Therefore, the solution should be
 Cultural change
 Female -centred strategies that support body-
positivity for women, rather than surgery (Nurka,
2019)
ABOUBAKR ELNASHAR

21. ABOUBAKR ELNASHAR
Aesthetic
Genital
Surgery
PROPONENTS

22. Proponents Of Aes G
1. We should maintain
 Patient autonomy for a woman requesting
surgery
 For reasons that she believes important to her,
even if severe anatomic pathology cannot be
exhibited (Cartwright, Cardozo, 2014)
‫الذاتي‬ ‫الحكم‬
ABOUBAKR ELNASHAR

23. 2. One of the most basic human rights is
 right to self-choice & self-governance,
 Free from
 interference by others
 limitations (including inadequate education or
inability to speak for themselves) to making an
autonomous choice (Cain et al, 2013)
‫الذاتي‬ ‫الحكم‬
ABOUBAKR ELNASHAR

24. 3. A patient's desire for
 Symmetry
 Lack of functional restriction
 Improved sexual function& relationships
positive self-image
are reasonable concerns
it is difficult to argue with
what a patient believes as real or perceived
anatomical distortion.
ABOUBAKR ELNASHAR

25. 4. As long as there is
proper preoperative counseling&
patients have realistic expectations about
outcomes,
they should be free to decide for Aes G.
ABOUBAKR ELNASHAR

26. 5. The initial controversies over Aes G have almost
settled down
Evidence suggesting that a number of procedures are
 Safe
 Effective
 Capable of treating to a considerable extent the
conditions associated with life vulvo-vaginal
changes.
 Delivering What Women Want (Magon, Alinsod;
2018)
ABOUBAKR ELNASHAR

27. ABOUBAKR ELNASHAR
6. Overall patient satisfaction rates: high(Goodman, 2008)
 Complications: 4% to 18% of women (Alter, 2008,
Goodman, 2010)

28. ETHICAL GUDELINES
 Evidence based
1. RCOG, 2013
2. SOGC, 2013
3. RANZCOG: Royal Australian& New Zealand College of
Obstetricians and Gynaecologists, 2011, 2015
4. FIGO: 2015
5. ACOG: 2007, 2013, 2017
6. ISSVD: International Society for the Study of Vulvovaginal
Disease, 2018
7. ISSVD & ICS, 2019
8. ACOG, 2020
 ALL state that
they cannot clearly support such surgery ethically.
(Goldstein, Jutrzonka, 2016)
ABOUBAKR ELNASHAR

29.  All (Goldstein, Jutrzonka, 2016)
1.There is a need to exercise caution in providing
Aes G. The message is clear: there is inadequate
evidence to support the beneficial claims of Aes G.
2.The need for informed consent & lack of clear
evidence on which to base such consent.
3.The procedures are not medically indicated& are
not part of the training of gynecologists or plastic
surgeons during residency.
ABOUBAKR ELNASHAR

30. 4. Conflict of interest and the veracity of web-based advertising.
5. Terms commonly used to advertise these procedures
are
 poorly understood
 marketing terms only
 Non-medical terms:
 Vaginal rejuvenation
 Clitoral resurfacing
 G-spot enhancement
ABOUBAKR ELNASHAR

31.  RCOG Ethics Committee, 2013
1. Counseling
1. Normal variations of vulva
2. Body image distress
3. Risks
4. Lack of reliable evidence of postive effects
2. Written records of physical & mental health reasons for the procedure
3. Advertising should not mislead people on
 what is deemed to be normal or
 what is possible with surgey
4.FGCS should not be undertaken within the NHS
unless it is medically indicated
ABOUBAKR ELNASHAR

32.  ACOG, 2017
 Minimal adequate long-term studies addressing
satisfaction, safety, and complication rates
 Use of fractional laser is not FDA approved for
gynecologic uses including vulvovaginal
atrophy or rejuvenation.
ABOUBAKR ELNASHAR

33. ABOUBAKR ELNASHAR
II. FDA 2018:
 Not approved any energy-based device for vag cosmetic
improvement or TT of symptoms associated with the GMS.
 Neither the safety nor effectiveness of these devices for
treatment
 Warns against use of laser-type devices as their use
may result in serious adverse events
 Vaginal burns
 Scarring
 Dyspareunia
 Recurring/chronic pain

34. III. The International Society for the Study of Vulvovaginal
Disease, 2018
• We strongly recommend against
 G-spot augmentation
 Hymenoplasty
 Vulvar& perianal bleaching/whitening
 Any FGCS with the intention of enhancing sexual
function
{lack of evidence to demonstrate benefit in the literature}.
• Robust evidence to support the use of laser or
radiofrequency to treat vaginal atrophy or “vaginal laxity” is
lacking ABOUBAKR ELNASHAR

35. ABOUBAKR ELNASHAR
 The International Society for the Study of
Vulvovaginal Disease (ISSVD) and
International Continence Society (ICS) , 2019
 Based on the available scientific evidence, with no
supporting long term follow-up data:
 use of LASER should, at present, not be
recommended for TT of
 Vaginal atrophy
 Vulvodynia, or
 Lichen sclerosus.

36.  The data for the role of LASER for
 Stress urinary incontinence&
 Vaginal laxity are inadequate to draw any
conclusions or safe practice
recommendations.

37. ABOUBAKR ELNASHAR
 ACOG 2020
 Lack of
 Published studies
 Standardized nomenclature
 Outcomes: risks & benefits.
 Counseling:
 Effectiveness: lack of high-quality data that support
 Potential complications: pain, bleeding, infection,
scarring, adhesions, altered sensation, dyspareunia, and
need for reoperation.

38. ABOUBAKR ELNASHAR
 Gynecologists should have sufficient training to recognize
women with
 Sexual dysfunction
 Psychiatric conditions:
 depression, anxiety
 body dysmorphic disorder.
 referral for evaluation before surgery.
 Gynecologist: inform patients about outcomes
 Substantial risk
 Safety & effectiveness have not been established.

39. ABOUBAKR ELNASHAR
 NICE 2021.
 The evidence on TV laser therapy for SUI or
urogenital atrophy does not show any short-
term safety concerns.
 Evidence on long-term safety & efficacy is
inadequate in quality and quantity.
 Therefore, this procedure should only be used
in the context of research.

40. You can get this lecture and 480 lectures from:
1.My scientific page on Face book: Aboubakr
Elnashar Lectures.
https://www.facebook.com/groups/2277448840913
51/
2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthwara St. Mansura