NHS Oxfordshire CCG



‘Are my labia normal?’ How to respondNeda Taghinejadi (Community Sexual and Reproductive Health Specialty Trainee, Oxford), Annabel Forsythe (Community Sexual and Reproductive Health Specialty Trainee, Oxford), Eleanor Holloway (Specialty Doctor in Sexual Health & Psychosexual Therapist, Oxford), Katy Vincent (Senior Pain Fellow & Consultant Gynaecologist, John Radcliffe Hospital), Brenda Kelly (Consultant Obstetrician, Clinical Lead for the Oxford Rose Clinic, John Radcliffe Hospital)CaseA 23 year old woman presents to you with concerns about the appearance of her genitals. She feels that her labia are ‘longer than they should be’ and not symmetrical. She has read online that this can be associated with health problems such as recurrent urinary tract infections and abnormal discharge. She also is aware from her online research that surgery to shorten her labia is possible and asks you to refer her to a specialist. BackgroundLabial reduction or labiaplasty is one of a growing range of cosmetic genital surgeries. There has been a marked increase internationally in requests for labiaplasty/labial reduction, with predictions that these procedures will embark upon a similar upwards trajectory to that taken by breast surgery1. As most procedures are done in the private sector, data on frequency is limited; however it has been reported that between 2015 and 2016 more than 200 girls under 18 had labiaplasty on the NHS and there has been a 45% increase in labiaplasties worldwide in all ages2.-19685165735What is driving this trend?Increase in hair removal practices Misrepresentation of normal genitalia in pornographyMisinformation online, in particular on social mediaLack of accurate information resources about normal genital variety00What is driving this trend?Increase in hair removal practices Misrepresentation of normal genitalia in pornographyMisinformation online, in particular on social mediaLack of accurate information resources about normal genital variety It can be difficult for GPs to respond to their patients' concerns. This may reflect limited awareness of wide variation in normality, however, it can also be challenging to explore patient motivation and reasons for seeking surgery in a short consultation frame. In many cases referrals to gynaecology or to plastic surgery are made in the hope that a specialist will persuade the woman that she is normal and deter her from surgery. However, the lack of immediate reassurance and referral to secondary care might be interpreted by the patient as proof of abnormality and the need for surgery3. The EvidenceHow much is ‘too much’?There is conflicting evidence on genital variety. Some papers site any distance from the base to the edge of the labia minora greater than 2cm as ‘hypertrophic’, but with little supporting evidence. One cross-sectional study demonstrated a wide variety in the dimensions of the labia minora, with width ranging from 0.7-5cm and length ranging from 2-10cm4. None of the women in the study had expressed any personal difficulty or sought cosmetic surgical alteration.Why does it matter?Women may commonly present with the following concerns:Concerns about appearance (size / asymmetry) Visibility through clothingChafing / discomfort Psychosexual problemsHealth concerns such as recurrent UTIs and BV/candidaThere is no evidence to support any direct association between genital size/shape and physical symptoms4,5.And what about surgery?There are as yet no controlled studies investigating the clinical effectiveness, the risks or the long-term outcomes of labiaplasty. Concerns have been raised regarding risks and complications of these procedures. The labia minora may have an important role in sexual function; long-term damage to sensitivity and sexual function may occur after labiaplasty, as surgery will disrupt nerve supply6. There is also an increasing awareness of the risks of developing new chronic pain after any surgical procedure. Although published data does not exist for labiaplasty specifically, the high density of nerve fibres within the labia and comorbid psychological distress that is often seen suggest that rates of postsurgical pain are likely to be at least as high as described for other procedures7.How about the ethics?The RCOG published an ethical opinion paper around female genital cosmetic surgery in 20136. They recommended that cosmetic genital procedures should not be carried out on women and girls under 18 years of age, irrespective of consent, because full genital development is not normally achieved before the age of 18. It could be argued, however, that it is not possible to gain informed consent from any woman as we currently are unable to provide evidence-based information regarding long-term risks and benefits of the procedure. It is also important to note that parallels have been drawn between female genital cosmetic surgeries and FGM due to the ‘cultural norms’ that may inform patients’ requests. To date, no doctors have been prosecuted for performing these cosmetic surgeries in the UK.Approaching the consultation40767001276985Referrals to specialist care should be carefully considered as it may validate her concerns. However, in the context of associated symptoms/ a firmly held belief that surgery is required, referral may be necessary. Patients under 25 should be referred to Dr Vincent (adolescent gynaecology) specifically. Expectations should be managed by emphasising that surgery will not be considered as described in the Lavender Statement. 020000Referrals to specialist care should be carefully considered as it may validate her concerns. However, in the context of associated symptoms/ a firmly held belief that surgery is required, referral may be necessary. Patients under 25 should be referred to Dr Vincent (adolescent gynaecology) specifically. Expectations should be managed by emphasising that surgery will not be considered as described in the Lavender Statement. Returning to the case, the key issue is to establish the reasons behind her request. For some women these will be purely related to appearance, but for others there may be associated physical symptoms such as pain, irritation, vaginal discharge or repeated UTIs. For all women, but particularly the under 18s, it is important to ensure there are no safeguarding issues and to act on these if identified. A genital examination should be offered for reassurance. However, more invasive examinations such as a bimanual or speculum should be reserved for cases where relevant associated symptoms are present. It is essential that the examination does not reinforce her beliefs and therefore both verbal and non-verbal cues are important. -476254000501219200317500-28638579375Discussion around ‘what is normal’ Offer examination 00Discussion around ‘what is normal’ Offer examination -295275151130Vulval skin-care (avoid hair removal, advise emollients) Consider cotton/loose fitting underwear00Vulval skin-care (avoid hair removal, advise emollients) Consider cotton/loose fitting underwear-29527536195Direct to resources (see below)If clear body dysmorphism/ psychological consider psychological referralIf under 18, parental support/education00Direct to resources (see below)If clear body dysmorphism/ psychological consider psychological referralIf under 18, parental support/educationPatient resourcesSo what is a vulva anyway? ()Centrefold? ()The Great Wall of Vagina () The Vulva Gallery ()References (1) Braun, V. (2010). Female genital cosmetic surgery: a critical review of current knowledge and contemporary debates. Journal of Women’s Health, 19(7): 1393-1407.(2) International Society of Aesthetic Plastic Surgery. (2017). ISAPS Global Statistics. <medical-professionals/isaps-global-statistics/>(3) Liao, L. M., Creighton, S. M. (2011).?Female genital cosmetic surgery: A new dilemma for GPs. British Journal of General Practice, 61,?7–8. (4) Lloyd, J., Crouch, N. S., Minto, C. L., Liao, L. M., Creighton, S. M. (2005).?Female genital appearance: “Normality” unfolds. BJOG: An International Journal of Obstetrics & Gynaecology, 112,?643–646.(5) Liao, L. M., Taghinejadi, N., Creighton, S. M. (2012).?An analysis of the content and clinical implications of online advertisements for female genital cosmetic surgery. British Medical Journal Open, 2.(6) RCOG Ethics?Committee.?(2013). Ethical Opinion Paper.?Ethical?considerations in relation to female genital cosmetic surgery (FGCS).(7) Correll D. (2017). Chronic postoperative pain: recent findings in understanding and management. F1000Res, 4;6:1054. ................
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